INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 15-16, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records conducted on November 15, 2017, the facility failed to ensure that all clinical staff met the requirements for their position.
Employee #9 was hired as high school level counselor assistant on 3/22/17. On September 10, 2017 was promoted to a counselor, however they did not have a qualifying degree in a related field.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC will ensure that any such staffing transitions, that encourage and reward positive staff performance in the care and delivery of professional services are documented more thoroughly to ensure accurate representation to the same for regulatory bodies. A review of the necessary protocols to accurately represent the same has been presented and reviewed with the newly appointed clinical supervisor on November 30, 2017. The Staff member in question was re-classified to their previous job title of Counselor Asst. effective November 22, 2017. During this meeting the staff member was also supported with their application to the PA Certification Board. The staff member is prepared to take their Certification Examination as soon as it is scheduled via the PA Cert. Board. Upon successful completion and acquisition of Certification, this staff member will be re-appointed to the position of Counselor et al. It is projected that such will completed by January 22, 2018. Any and all future such promotional recommendations for clinical staff members will require the presentation of all necessary data and supporting documentation to the Center Director and or their designee to ensure all areas of 704.7 are met prior to the actual promotion of same. |
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
|
Observations
Based on a review of supervision files and personnel records on November 15, 2017, the facility failed to ensure that a counselor assistant received a positive assessment prior to the assignment of a full case load.
Employee #9 was hired as high school level counselor assistant on 3/22/17. There was no documentation of a positive assessment as a counselor assistant prior to assigning a full case load.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC will ensure that any such staffing transitions, that encourage and reward positive staff performance in the care and delivery of professional services are documented more thoroughly to ensure accurate representation to the same for regulatory bodies. A review of the necessary protocols to accurately represent the same has been presented and reviewed with the newly appointed clinical supervisor on November 30, 2017. An additional review to support the documentation of a positive assessment being completed and filed in ones' personnel record was also completed on this date. Upon this staff members acquisition of their PA Certification, such documentation will be added to support this staff members re-appointment to the position of Counselor. It is projected that such will be resolved by January 22, 2018. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of supervision log conducted on November 15, 2017, the facility failed to ensure that a counselor assistant received direct observation for the first three months of employment.
Employee #9 was hired as high school level counselor assistant on 3/22/17. A supervision log, which contains a column to denote when direct observation occurs, indicated that supervision was provided on 3/24/17, 3/29/17, 4/5/17, 4/12/17, 4/13/17, 4/18/17, 4/26/17, 4/27/17, 5/5/17, 5/17/17, 6/23/17, 6/27/17, 7/6/17, 7/12/17, 7/20/17, 7/26/17, 8/2/17, 8/11/17, 8/18/17, 8/24/17, 8/30/17, however none of the supervision was documented as direct observation.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC clinical management team will ensure that if/when a counselor assistant is placed into a clinical position on site, that we adhere to the protocols as set forth by regulation 704.9 and as is present on the documentation on site that supports the same to ensure that Direct Observation is utilized as a clinical oversight and training of a counselor assistant within their role on site, during the first three (3) months; and beyond if necessary. A review of the protocol and regulation was presented by this author to the newly appointed clinical supervisor on November 30, 2017. This corrective measure is expected to be adhered to as of November 30, 2017 forward. Such documentations will be maintained in the staff members personnel record. This too was discussed and reviewed with the newly hired Office Mgr. on November 30, 2017. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of personnel records conducted on November 15, 2017, the facility failed to ensure that a counselor assistant satisfactorily completed the qualifications for counselor prior to promotion.
Employee #9 was hired as high school level counselor assistant on 3/22/17. On September 10, 2017 was promoted to a counselor, however employee #9 did not have a qualifying degree in a related field.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC will ensure that any such staffing transitions, that encourage and reward positive staff performance in the care and delivery of professional services are documented more thoroughly to ensure accurate representation to the same for regulatory bodies. A review of the necessary protocols to accurately represent the same has been presented and reviewed with the newly appointed clinical supervisor on November 30, 2017. The Staff member in question was re-classified to their previous job title of Counselor Asst. effective November 22, 2017. During this meeting the staff member was also supported with their application to the PA Certification Board. The staff member is prepared to take their Certification Examination as soon as it is scheduled via the PA Cert. Board. Upon successful completion and acquisition of Certification, this staff member will be re-appointed to the position of Counselor et al. It is projected that such will completed by January 22, 2018. Any future such staffing adjustments will require the immediate supervisor to present any and all supporting data and documentation to the Center Director, and/or their designee, to ensure completion and adherence to this regulation prior to actual staffing promotional adjustments.
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records conducted on November 15, 2017, the facility failed to ensure that a counselor received the required 25 training hours during the training year from January 1, 2016 through December 31, 2016.
Employee #5 was hired as a counselor on April 29, 2013 and promoted to Lead Counselor on September 25, 2017. Training files were reviewed for the period from January 1, 2016 through December 31, 2016 . During that time employee #5 received only 10 documented hours of training.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC Clinical Mgmt. team will ensure that each and every clinical staff member completes the required number of annual training's expected during a calendar year. The staff member in question is a licensed professional counselor as well as a certified substance abuse counselor who is required to maintain more than 60 hours of training's, albeit in a two (2) year period. As such, and as discussed and reviewed with the auditor, this staff member completed the majority of these training's during the current calendar period, with minimal attendance during the 2016 calendar period. A review of staff members needs to adhere to the appropriate level of training's each year, and to spread out said training's year over year, was presented and reviewed during the full staff monthly meeting held on December 6, 2017. This presentation also served as a reminder to all staff to be cognizant and aware of their annual training needs and ensure that such is provided to the Office Mgr. so that it may be accurately represented in ones' personnel file. As such, this date will also serve as the corrective action date to ensure adherence to 704.10. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report conducted on November 15, 2017, the facility failed to ensure that employees #8 & 9 did not exceed 35 active clients.
Employee #8 works 37.5 hours and has 46 clients yielding a ratio of 43:1.
Employee #9 works 37.5 hours and has 47 clients yielding a ratio of 44:1.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC Clinical Mgmt. completed a thorough review of the existing case loads and has corrected the ratio discrepancies noted herein. A review of such on November 30, 2017, as well as during the audit, demonstrated that their was the ability to have a balanced ratio with staff to patient ratio's. It is also noted that with Center continued growth, it is necessary to add additional clinical staffing. As such a position posting has been submitted and is presently running to seek out qualified clinical staff to join the Dunmore CTC team. Clinical Team leaders have been charged with maintaining an accurate assessment of the staff to Pt. ratio and to provide recommendations for adjustments and/or staffing additions to ensure compliance to 704.12. A full review was provided during the Monthly Staff meeting on December 6, 2017 which will serve as the corrective action date. Ongoing weekly reviews will be conducted by Clinical Team Leaders and the Clinical Supervisor with recommendations to be offered to the CD if/when necessary, yet in advance of non-compliance. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on a review of physican hours and a review of the physician's schedule conducted on November 15, 2017, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the weeks from July 23, 2017 through November 10, 2017. The facility was not in compliance for the following weeks:
July 23-29-- census 333, coverage 29.5 hrs
August 20-26-- census 345, coverage 14.25 hrs
September 3-9-- census 357, coverage 27 hrs
September 17-23-- census 352, coverage 27.5 hrs
September 24-30-- census 354, coverage 25.5 hrs
October 1-7-- census 358, coverage 30.65 hrs
October 8-14-- census 360, coverage 26.25 hrs
October 15-21-- census 356, coverage 18.45 hrs
October 22-28-- census 358, coverage 29.5 hrs
October 29-November 4-- census 361, coverage 19.75 hrs
November 5-11-- census 361, coverage 22.25 hrs
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Following the unexpected and untimely resignation of the Regional Medical Director for the HOI-Project in May 2017, this author immediately commenced a search for additional medical personnel to contract with for patient care. The intention of filling this position was focused on the most qualified and appropriate hire to ensure nothing short of exceptional patient care; such did take time. An additional Physician was identified and, following a lengthy contract development, has commenced services on site in Dunmore CTC prior to the audit. As this physician continues to acclimate to the Center and patients, an increase to their days/hours offered on site will also be realized. Such is planned for January 22, 2018. Such will place Dunmore CTC in compliance to this metric. Yet, with the projected census growth, based on trending data, it is necessary to seek additional medical personnel. As such, this author has commenced a search to add additional Physician Extender hours with the hire of an another physician extender. This process has commenced at the time of this draft. As the appropriate hire is necessary to ensure nothing short of exceptional patient care, it is expected that this process may take some time, yet is projected to be resolved and an additional extender added to the Center Medical Team by January 29, 2018. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
|
Observations
Based on a review of physican hours and a review of the physician's schedule conducted on November 15, 2017, the facility failed to ensure that a narcotic treatment physician provided at least one third of the required physician time.
A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the weeks from July 30, 2017 through November 10, 2017. The facility was not in compliance for the following weeks:
July 23-29-- 10.9 required hours, 7.5 actual physician hours worked.
September 3-9-- 8.9 required hours, 0 actual physician hours worked.
October 15-21-- 6.1 required hours, 4 actual physician hours worked.
October 22-28-- 9.7 required hours, 4 actual physician hours worked.
October 29-November 4-- 6.5 required hours, 5.5 actual physician hours worked.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Following the unexpected and untimely resignation of the Regional Medical Director for the HOI-Project in May 2017, this author immediately commenced a search for additional medical personnel to contract with for patient care. The intention of filling this position was focused on the most qualified and appropriate hire to ensure nothing short of exceptional patient care; such did take time. An additional Physician was identified and, following a lengthy contract development, has commenced services on site in Dunmore CTC prior to the audit. As this physician continues to acclimate to the Center and patients, an increase to their days/hours offered on site will also be realized. Such is planned for January 22, 2018. Such will ensure that a narcotic treatment physician provide at least one third of the required physician time and place Dunmore CTC in compliance to this metric. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Seven client records were reviewed on November 16, 2017, four of which were methadone client records; the facility failed to document an average of 2.5. hours of psychotherapy per month in client records, #2 & 6.
Client #2 was admitted on 12/10/15 and was an active client at the time of the licensing inspection.
The facility documented no-show notes for individual sessions on 1/18/17, 2/2/17, 3/31/17, 5/11/17, 6/9/17, 7/10/17, 8/16/17, 9/11/17 9/18/17 and 11/6/17.
Client #2 attended a 60 minute individual session on 1/26/17 and a 30 minute session on 4/21/17; #2 also attended a 90 minute group on 1/25/17 and 8/19/17.
Client #6 was admitted on 12/13/16 and was discharged on 4/11/17.
The facility documented no-show notes for an individual session on 2/3/17, and an excused note for 1/27/17.
Client #6 attended a 60 minute individual session on 2/1/17, 2/15/17 and 2/28/17.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
On November 30, 2017 this author completed a review of 715.19(1) with the Clinical Management Team. Mgmt. team members where instructed to identify procedures to correct the clinical engagement for patients on site, identifying processes by which this may be realized and be prepared to present their ideas and plans during our next Clinical Team meeting with, all clinical staff, on January 12, 2018. Addition of clinical team members, along with enhanced group offerings were placed on the table by this author during the Nov. 30th meeting. The entire clinical team will reconvene and implement final, mutually agreed to plans geared to increase and enhance clinical program offerings to fully commence on January 15, 2018. The submission of weekly Services Rendered will be submitted to the Weekly Supervisor, and/or their designee, to ensure accurate and timely engagement to patient care and needs on a regular and on-going basis. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Seven client records were reviewed on November 16, 2017, four of which were methadone client records; the facility failed to document a discharge summary in client record #6.
Client #6 was admitted on 12/13/16 and was discharged on 4/11/17.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
On November 30, 2017 this author completed a review of 715.23(b)(23) with the Clinical Management Team. Mgmt. team members where instructed to commence a review, with their teams, all discharged patient records to ensure that there are no outstanding discharge summaries that remain incomplete. This responsibility to complete regular (Weekly or bi-weekly checks) on the same has been reassigned to the newly appointed clinical supervisor and the clinical team leaders to ensure timely completion to this, and any, clinical documentation that is required. Such corrections are to be completed by the clinical team meeting slated for January 12, 2018. A review of timely completion of the same will also be presented during this clinical team meeting to ensure compliance moving forward and that is sustainable with potential clinical staffing changes and caseload reassignments; as such may present itself. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
|
Observations
Seven client records were reviewed on November 16, 2017, four of which were methadone client records; the facility failed to document a follow up information in client record #6.
Client #6 was admitted on 12/13/16 and was discharged on 4/11/17.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
On November 30, 2017 this author completed a review of 715.23(b)(24) with the Clinical Management Team. Mgmt. team members where instructed to commence a review, with their teams, all discharged patient records to ensure and correct any outstanding follow up contacts in patient records.
This responsibility being shared with additional clinical team members and to be completed on a regular basis (Weekly or bi-weekly). A review of this has been assigned to the newly appointed clinical supervisor and clinical team leaders to ensure timely completion and documentation to all follow up patient contacts post discharge. Such corrections are to be completed by the clinical team meeting slated for January 12, 2018. A review of timely completion of the same will also be reviewed during this clinical team meeting and full staff meeting, to ensure compliance moving forward. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Seven client records were reviewed on November 16, 2017, four of which were methadone client records; the facility failed to update the treatment plan in client records, #1, 2.
Client #1 was admitted on 11/25/16 and was an active client at the time of the licensing inspection.
A treatment plan update was documented on 2/17/17; a treatment plan update was due by 4/17/17 but was not documented until 5/4/17.
Client #2 was admitted on 12/10/15 and was an active client at the time of the licensing inspection.
A treatment plan update was documented on 12/13/16; a treatment plan update was due by 2/13/17 but was not documented until 3/8/17. Additionally, a treatment plan update was documented on 6/9/17; a treatment plan update was due by 8/9/17 but was not documented until 8/28/17.
Client #3 was admitted on 1/24/17 and was an active client at the time of the licensing inspection.
A treatment plan update was documented on 4/10/17; a treatment plan update was due by 6/10/17 but was not documented until 7/24/17. Additionally, a treatment plan update was due by 9/24/17 but was not documented until 10/24/17.
Client #4 was admitted on 9/6/16 and was discharged on 3/29/17.
A treatment plan update was documented on 1/4/17; a treatment plan update was due by 3/4/17 but was not documented at the time of the licensing inspection.
Client #6 was admitted on 12/13/16 and was discharged on 4/11/17.
A comprehensive treatment plan was documented on 1/9/17; a treatment plan update was due by 3/9/17 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
On November 30, 2017 this author completed a review of 709.92 with the Clinical Management Team. Clinical management team members where instructed to commence a review, with their teams, as to the timely completion of all treatment planning preparation and completion.
A constant and thorough review of the timeliness to treatment plan development and updates, to ensure and correct deficiencies in this area, has been implemented with the reorganization and addition of the newly appointed clinical supervisor and clinical team leaders. This responsibility being shared with these team members will afforded a greater accountability to staff and patient attention. Reviews of such are projected to be completed on a regular basis (Weekly or bi-weekly). A thorough review of this matter will be presented, and discussed, with all clinical team members during the clinical team meeting slated for January 12, 2018 with full implementation expected to commence on January 15, 2018 and forward. |