INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 8, 2015 through September 10, 2015 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 not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the project's Staffing Requirement Facility Summary Reports (SRFSR), the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings inclued:
The Staffing Requirements Facility Summary Reports for the 4 facilities contained within the project were reviewed on September 8, 2015. The equivalent of 22 full-time counselors were employed within the project at the time of the inspection. This would require at least 2 full-time clinical supervisor.
The project's SRFSRs listed a total of 2 clinical supervisors, who also were listed as counselors and having a full caseload; therefore, they are unable to provide full-time clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Center Director will submit a Personnel Action Request to human resources on 10/12/15. This Personnel Action Request being submitted to hire an additional clinician, or counselor assistant. This staffing action will allow for the existing clinical supervisors caseload to be transferred to the new hire, while also ensuring that the counselor?s caseload does not exceed 35:1. When the hiring process is completed, this will create a dynamic for greater supervision and case review by the clinical supervisors, who will carry a caseload of no more than 5 patients. The Center Director will be responsible for ensuring that the action plan is implemented as well as continuously monitor the 8:1 counselor to clinical supervisor ratio, with the clinical supervisor, to ensure that the facility maintains compliance with the regulated ratio.
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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.
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Observations
Based on a review of personnel training records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in three of seven personnel records reviewed.
The findings include:
Seven personnel records were reviewed on September 8, 2015. Six personnel records pertained to counselors with the requirement of the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records, #2, 6, and 7.
The project's training year was from January 1, 2014 through December 31, 2014.
Employee #2 was hired as a counselor on April 1, 2012 and was still in that position at the time of the inspection. There was only 10 clock hours of training documented in the employee file for the 2014 training year.
Employee #6 was hired as a counselor on October 1, 2012 and was still in that position at the time of the inspection. There was only 15 clock hours of training documented in the employee file for the 2014 training year.
Employee #7 was hired as a counselor on November 18, 2013 and was still in that position at the time of the inspection. There was only 16.5 clock hours of training documented in the employee file for the 2014 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Center Director will ensure that quarterly reviews are conducted to ensure that clinical personnel are on track with expected annual trainings.
The use of a tracking mechanism will be assigned to ensure that staff progress may be self monitored and reviewed on a regular basis.
Oversight to staff compliance will be delegated to thier direct report(s) and Administrative support staff.
The aforementioned will be presented to all staff during the October 14, 2015 staff meeting. Additionally, at that same time, a review of trainings completed for this year will be conducted with the opportunity for staff to complete and fill in thier training tracker tool. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that a complete, informed and voluntary consent to release information form was obtained in three of seventeen client records reviewed.
The findings included:
Seventeen client records requiring complete informed and voluntary consent to release information forms were reviewed on September 8, 2015 through September 10, 2015. The facility failed to ensure that the person to whom the disclosure was made and the signature and date of the witness were completed on the consent to release information form in client records #1, 2, and 6.
Client #1 was admitted into treatment on October 17, 2014 and was still an active client at the time of the inspection. A release of information to the emergency contact was signed and dated by the client on 10/17/14; however; the release of information form did not include the signature and the date of the witness at the time of the inspection.
Client #2 was admitted into treatment on August 25, 2015 and was still an active client at the time of the inspection. A release of information to the emergency contact was signed and dated by the client on 8/25/15; however; the release of information form did not include the signature and the date of the witness, the purpose of the disclosure, and the person to whom the disclosure was made to at the time of the inspection.
Client #6 was admitted into treatment on December 11, 2014 and was still an active client at the time of the inspection. A release of information to the emergency contact was signed and dated by the client on 10/17/14; however; the release of information form did not include the signature and the date of the witness at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Center Director intends to work with IT to have the Emergency Contact Releases prepared within the Center's Electronic Health Record (EHR), SMART.
With this document being placed into SMART. The existing admission procedures on site via the EHR require that all such documents to be completed, in their entirety, in order to move forward with the admission process.
A request for such and adjustment to the EHR and the inclusion of this docuemnt has been submitted as of this redraft.
Completion of this adjusment will be available and noted within patient records.
All existing records as identified via this audit will be corrected with the developing of a new emergency contact release to include the emergency contact information, signed by the patient and authorized staff witness. This effort will be completed by 10/9/2015. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to ensure that a copy of the signed client consent was offered to the client in six of seventeen client records reviewed.
The findings included:
Seventeen client records requiring informed and voluntary consent to release information forms were reviewed on September 8, 2015 through September 10, 2015. The facility failed to document that the signed consent forms were offered to the client in client records, #1, 2, 3, 6, 9, and 10.
Client #1 was admitted into treatment on October 17, 2014 and was still an active client at the time of the inspection. There was a consent to release form to the emergency contact signed and dated on 10/17/14 that did not include documentation that the client was offered a copy of each form.
Client #2 was admitted into treatment on August 25, 2015 and was still an active client at the time of the inspection. There was a consent to release form to the emergency contact signed and dated on 8/25/15 that did not include documentation that the client was offered a copy of each form.
Client #3 was admitted into treatment on April 10, 2015 and was still an active client at the time of the inspection. There was a consent to release form to the emergency contact signed and dated on 4/6/15 that did not include documentation that the client was offered a copy of each form.
Client #6 was admitted into treatment on December 11, 2014 and was still an active client at the time of the inspection. There was a consent to release form to the emergency contact signed and dated on 12/8/14 that did not include documentation that the client was offered a copy of the consent to release form.
Client #9 was admitted into treatment on November 18, 2014 and was discharged on May 21, 2015. There was a consent to release form to the emergency contact signed and dated on 11/14/14 that did not include documentation that the client was offered a copy of the consent to release form.
Client #10 was admitted into treatment on June 24, 2014 and was discharged on October 3, 2014. There was a consent to release form to the emergency contact signed and dated on 7/10/14 that did not include documentation that the client was offered a copy of the consent to release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Center Director intends to work with IT to have the Emergency Contact Releases prepared within the Center's Electronic Health Record (EHR), SMART.
Part of the IT request will be to add a check box acknowledging a patients response to the offering of a copy of said release/authorization.
With this document being placed into SMART and the admission procedures on site, it will prove necessary for all such documents to be completed in their entirety in order to move forward with the admission process.
A request for such and adjustment to the EHR and the inclusion of this docuemnt has already been submitted to IT.
All existing records as identified via this audit will be corrected with the developing of a new emergency contact release to include the emergency contact information, signed by the patient and authorized staff witness; and the inclusion of a written statement as to the offering of a copy of said release to the patient and their response.
This effort will be completed by 10/9/2015. |
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.
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Observations
Based on a review of client records, the facility failed to review and update the treatment and rehabilitation plan within the regulatory 60 day timeframe in two of three client records reviewed.
The findings include:
Three client records requiring updated treatment and rehabilitation plans within 60 days were reviewed on September 8, 2015 through September 10, 2015. The facility failed to document updated treatment plans within 60 days in client records,# 8 and 16.
Client #8 was admitted into outpatient treatment on February 17, 2015 and was still an active client as of the date of the on-site inspection. There was a treatment plan update completed on 04/27/2015 and another update was due no later than 06/27/2015; however, the treatment plan was completed after the 60 day regulatory timeframe on 07/22/2015.
Client #16 was admitted into outpatient treatment on July 1, 2014 and was discharged on June 24, 2015. There was a treatment plan update completed on 02/28/2015 and another update was due no later than 04/28/2015; however, the treatment plan was completed after the 60 day regulatory timeframe on 06/19/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Center Director will meet with the Senior Clinician to ensure that a more thorough review is conducted of Pt. charts and that clinical staff are utilzing the tools available to them via the EHR so that the timely completion of such documentation is accomplished.
As discussed during the licensing visit process related to this matter, if/when such a Pt. may be indisposed due to confinement/incarceration, notation will be made at the appropirate 60 day mark on the Tx plan; specifically on the 'Progress since last Plan' line, to infer that the plan remains "as is"...pending Pt.'s return to treatment from confinement/incarceration. Thereby ensuring that said observation is resolved. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in two of three client records reviewed.
The findings include:
Three client records requiring assurance that counseling services are provide to the client as prescribed in the treatment and rehabilitation plan were reviewed on September 8, 2015 through September 10, 2015. The facility failed to provide counseling services in accordance with the treatment plan in client records # 16 and 17.
Client #16 was admitted into outpatient treatment on July 1, 2014 and was discharged on June 24, 2015. The client signed and dated the treatment plan on 8/1/2015, which indicated that the client was to receive group sessions once a week. The client's last group attendance was documented on 03/28/2015; therefore, for the months of April, May, and June 2015 there was no documentation of attendance, no shows/cancellations, or whether the client was stepped down from that service in the client chart at the time of the inspection.
Client #17 was admitted into outpatient treatment on July 10, 2014 and was discharged on November 20, 2014. The client signed and dated the treatment plan on 8/4/2015, which indicated that the client was to receive group sessions once a week. The client should have attended four times per month; however, attendance was only documented for one session in October 2014 and one session in November 2014 with no documentation of attendance, no shows/cancellations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Center Director will review with the Senior Clinician and Clinical Team on October 14, 2015 the need to ensure that appropriate documentation is maintained with regards to Pt. compliance to Treatment plan expectations and session attendance.
The need to review treatment plan recommendations and/or patient accountatility will also be discussed. The need to modify one or the other so as to meet program and Patient needs will prove necessary.
On-going case consult sessions and MDT will be used to monitor said compliance to Tx and documentation as noted within this observation.
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709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes case consultation notes and follow-up information in two of three client records reviewed.
The findings include:
Three client records requiring a complete client record on an individual were reviewed on September 8, 2015 through September 10, 2015. The facility did not provide a complete client record for clients, #16 and 17.
Client #16 was admitted into outpatient treatment on July 1, 2014 and was discharged on June 24, 2015. The facility failed to include documentation of any case consultation notes in the client record at the time of the inspection.
Client #17 was admitted into outpatient treatment on July 10, 2014 and was discharged on November 20, 2014. The facility failed to include documentation of any case consultation notes in the client record at the time of the inspection. Additionally, the facility failed to include documentation of follow-up information after the client was discharged.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the October 14, 2015 all staff meeting a review of Case Conlsultations and discharged patient follow up procedures will be discussed; along with a review of the on-site Policy to the same.
Staff assignments will be revised to ensure compliance to a timely attention to both of these clinical procedures.
The Center Director will also reach out to IT to ascertain if these services may be 'called up' via the EHR with a reminder notification to assigned staff. If so, such a modification will be added to the EHR so that the discharging Primary Clinician is provided with a timely reminder of this service due so that it may be completed and documented as such.
Additionally, clinical and administrative staff will utilize a basic excel table to track services due, such as case consult and discharge follow up contacts. The table will be part of each staff members weekly review for completion and will be part of supervisory discussions and review for completion.
The aforementioned template will be prepared and presented to all staff during the Oct. 14 staff meeting. |