INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on November 12-13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Habit OPCO-Dunmore 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of 15 staff records. The facility failed to ensure all staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Staff # 12 was hired on June 5, 2017 as an Office Manager and did not have HIV/AIDS or TB/STD training at the time of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 01/01/2021, all newly hired staff will complete HIV/AIDS and TB/STD training within the first year of hire, in accordance with the State regulation. The Office Manager will monitor all training requirements on a quarterly basis and report updates to the CTC Director via a quarterly training report.
As of 11/24/2020, there are no available seats for the required HIV/AIDS and TB/STD trainings in the Northeast Region, nor on-line. When a training becomes available, Employee #12 will be registered to attend. |
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.
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Observations
Based on a review of 11 staff, the program failed to comply with counselor caseload not exceeding 35 active clients.
Counselor #10 who was hired on March 25, 2019 had a caseload of 36:1.
Counselor #11 who was hired on July 13, 2020 had a caseload of 37:1.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
By February 2021, CTC Director will hire two additional staff to correct the issue of ratio compliance. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During a fire drill conducted on January 10, 2020. the facility failed to maintain a written fire drill record including the time the fire drill took place, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, and problems encountered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month and document the drill using the designated Emergency drill form, which notes the time the fire drill took place, the time it took to evacuate, the exit route used, the number of people in the facility at the time of the fire drill, and any problems that may have been encountered during the drill. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation quarterly. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
During a fire drill conducted on January 10, 2020. the facility failed to prepare alternate exit routes to be used during fire drills.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from licensing inspection November 19, 2019.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month and document the drill using the designated Emergency drill form. The CTC Director will monitor compliance in this area by ensuring that alternative exit routes are used during the fire drills. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
During a fire drill conducted on January 10, 2020. the facility failed to set off a fire alarm or smoke detector during the fire drill.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from licensing inspection November 19, 2019.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month, by sounding an alarm to initiate the start of the drill, and document the drill using the designated Emergency drill form. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation quarterly. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of incident reports on November 13, 2020, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the presence of police, fire or ambulance personnel.
An incident occurred on April 6, 2020 involving the presence of police, fire or ambulance personnel and was not submitted to the department until April 14, 2020.
An incident occurred on February 6, 2020 involving the presence of police, fire or ambulance personnel and was not submitted to the department until February 10, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director will ensure that all Unusual incidents occurring at the facility be submitted within 3 business days following the unusual incident occurring. The CTC Director will work with the Director of Quality and Compliance to complete and submit the unusual incidents within the 3 business day requirement. |
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
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Observations
Based on a review of physician's hours on November 12-13, 2020 the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
From July 13-19, 2020 the program had a census of 550 which required 55.0 physician hours, the program was short 3.3 physician hours.
From July 20-26, 2020 the program had a census of 552 which required 55.2 physician hours, the program was short 7.7 physician hours.
From August 3-9, 2020 the program had a census of 549 which required 54.9 physician hours, the program was short 1.8 physician hours.
From August 10-16, 2020 the program had a census of 551 which required 55.1 physician hours, the program was short 8.3 physician hours.
From August 17-23, 2020 the program had a census of 553 which required 55.3 physician hours, the program was short 19.8 physician hours.
From August 24-30, 2020 the program had a census of 554 which required 55.4 physician hours, the program was short 13.15 physician hours.
From September 7-13, 2020 the program had a census of 556 which required 55.6 physician hours, the program was short 9.5 physician hours.
From September 14-20, 2020 the program had a census of 560 which required 56.0 physician hours, the program was short 2.6 physician hours.
From September 21-27, 2020 the program had a census of 557 which required 55.7 physician hours, the program was short 8.45 physician hours.
From September 28- October 4, 2020 the program had a census of 560 which required 56.0 physician hours, the program was short 10.25 physician hours.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from licensing inspections November 15, 2018 and November 19, 2019.
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Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 12/01/2020 and will be submitted to the medical staff monthly to ensure there is adequate coverage of PA/CRNP and MD per census requirements. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage between MDs and PA/CRNP. |
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.
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Observations
Based on a review of eight patient records on November 12-13, 2020, the narcotic treatment program failed to provide one out of eight patients 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.
Patient #8 was admitted on February 2, 2019 and was current at the time of the inspection. Patient #8 had 30 minutes of individual and 2 hours of group psychotherapy in September 2020.
Patient #8 had 30 minutes of individual and 2 hours of group psychotherapy in October 2020.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from licensing inspections November 15, 2018 and November 19, 2019.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The Clinical Supervisor reviewed the requirements for counseling services with all counselors on 11/24/2020. As of 12/01/2020 each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor, noting the number of hours of both individual and group counseling that each patient is receiving per month. The Clinical Supervisor will review the reports in individual and group supervision monthly. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |