INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted from October 11, 2016 to October 13, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite 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 the inspection:
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records on October 11, 2016, it was determined that the project director of the facility did not meet the experiential requirements for the position. Considering the educational attainment of the current project director, he is required to have at least three years of experience in a human service agency, which includes supervision, direct service, and program planning. At the time of the inspection, the project director had no documented experience providing direct services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director role will be transition to Jonathon Wasp effective 11/14/2016. Mr. Wasp meets all of the qualifications identified in the regulations including direct service. A formal notification will be submitted to the department by Mr. Wasp along with supporting documentation validating his qualifications for the role.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A review of the September 2015 through September 2016 fire drill logs was conducted during the onsite inspection. The facility failed to conduct unannounced drills during the 2016 months of April, May, June, August, and September. Additionally, the logs for the months of January 2016, February 2016, March 2016, and July 2016 failed to include the number of persons in the facility at the time of the drill and whether a fire alarm or smoke detector was operative at the time of the drill. Also, the logs for the months of January 2016, February 2016, March 2016, and July 2016 failed to include the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the same was conducted by the Center Director and the Safety Committee members on Friday, October 14, 2016. Corrections and training offered to all staff related to the same during a supervisory meeting with the Admin. Asst., Security and Safety committee members held on Monday October 17, 2016. A thorough review to adhere to the 'most stringent' policy completed and corrections made to the same.
During this training, and subsequent supervisory meeting(s), Security supervisor (Admin. Asst.) and the Clinical Supervisor, in concert with the Health & Safety committee members, will review and ensure that monthly drills are conducted as outlined in regulation P273. This will be an ongoing function and job duty of these management and Team members. A further presentation to all on site will be completed during the next monthly staff meeting on Thursday 11/17/2016.
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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 the review of the physician timesheets for the months of July, August, September, and October 2016, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the month of July 2016 and the first week of August 2016.
During the week of July 3-9, 2016, the patient census was 273. The facility was required to provide at least 27.3 physician hours. There were 9 physician hours documented.
During the week of July 10-16, 2016, the patient census was 274. The facility was required to provide at least 27.4 physician hours. There were 12 physician hours documented.
During the week of July 17-23, 2016, the patient census was 278. The facility was required to provide at least 27.8 physician hours. There were 12 physician hours documented.
During the week of July 24-30, 2016, the patient census was 273. The facility was required to provide at least 27.3 physician hours. There were 12 physician hours documented.
During the week of July 31, 2016 to August 6, 2016, the patient census was 277. The facility was required to provide at least 27.7 physician hours. There were 4 physician hours documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is noted and known that during the period in question there may be a lapse in such coverage in order to on-board additional medical personnel to best meet the needs of our population. As such, the on-boarding of the new physician extender on August 8, 2016, did create an overlap to this coverage. As such it was discussed and noted during the audit, and at the time of the exit, that this matter has been corrected as of August 8, 2016; and Dunmore CTC is currently in compliance to the regulations.
Pursuant to this, and with the on-boarding of the CRNP-Physician Extender, it will be added to their duties to ensure on-going medical coverage remains adequate and meeting all of the requirements of M025. As dictated by the ratios contained therein, it will be the responsibility of the Center Director to ensure, if and when necessary, additional hours are added to either the existing Physicians and/or Physician Extender where appropriate to maintain compliance.
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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 patient records, the facility failed to provide patient # ' s 1, 3, and 7 with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment.
Patient # 1 was admitted on April 9, 2015 and discharged on September 26, 2016. In July 2016, the patient had 30 minutes of individual therapy and 1.5 hours of group therapy. In August 2016, the patient had 30 minutes of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.
Patient # 3 was admitted on April 28, 2016 and was an active patient at the time of inspection. In July 2016, the patient had one hour of individual therapy and 0 hours of group therapy. In August 2016, the patient had 0 hours of individual therapy and 0 hours of group therapy. In September 2016, the patient had 30 minutes of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.
Patient # 7 was admitted on February 4, 2016 and was discharged on July 28, 2016. In April 2016, the patient had 0 hours of individual therapy and 0 hours of group therapy. In May 2016, the patient had 1 hour of individual therapy and 0 hours of group therapy. In June 2016, the patient had 0 hours of individual therapy and 1.5 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A thorough review of Pt. engagement and services rendered with the Center Director, Clinical Supervisor and the Clinical Team has commenced as of October 14, 2016 in response to the comments noted to 715.19(1). Based on existing staffing needs, at the time in question, there had been significant staffing pattern changes and adjustments made during the time period in question; as noted and reviewed during this audit and exit; in order to address the same. Dunmore CTC being re-staffed fully as of September 21, 2016, along with on-going weekly Clinical Team meetings and tracking mechanisms being placed into action as a result of these findings, it is expected that such matters will be corrected. On-going meetings with the Center Director & Clinical Supervisor, along with the Regional Clinical Services Coordinator will ensure compliance to the same moving forward. A review of the progress to this end will be completed on November 30, 2016 with the anticipation of observable corrective trending.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
During the licensing inspection from October 11, 2016 to October 13, 2016, a review of fire drill logs was conducted. During the review, it was discovered that the facility had an unusual incidents occur on February 28, 2016, March 10, 2016, April 7, 2016, and July 4, 2016, all of which required either fire, police, or ambulance personnel onsite. Upon further inspection, it was discovered that the facility had not submitted written unusual incident reports for any of the aforementioned incidents to the Department within the regulatory 48 hour timeframe.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
A review of the same was conducted by the Center Director and the Safety Committee members on Friday, October 14, 2016. Corrections and training offered to all staff during this supervisory meeting with the Admin. Asst., Security and Safety committee members held on Monday October 17, 2016. A review as to the ability for Security and Safety team members to use 'real scenarios' as evidence of Drills was confirmed, yet in such cases that warrant compliance to 715.28(c)(1-5) it is necessary to ensure such is brought to the attention of the CD in order to file the appropriate paperwork with the State. Those outstanding 'drill' scenarios that require the same will be filed with the State by Friday, November 4, 2016. Any and all such scenarios will be in full adherence to 715.28(c)(1-5) moving forward.
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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 patient records, patient records #1, 3, 4, 6, 9, and 10 had treatment plan updates completed after the regulatory timeframe of 60 days at the time of the inspection.
Patient #1 was admitted on April 9, 2015 and was discharged on September 26, 2016. There was a documented treatment plan update completed on August 31, 2015 but no treatment and rehabilitation plan update until February 17, 2016.
Patient #3 was admitted on April 28, 2016 and was an active patient at the time of inspection. The comprehensive treatment and rehabilitation plan was completed on July 8, 2016 and the update was due no later than September 8, 2016; however, the update was not completed until September 29, 2016.
Patient #4 was admitted on April 14, 2015 and was discharged on August 25, 2016. A treatment plan update was due no later than November 16, 2015; however, the update was not completed until March 15, 2016.
Patient #6 was admitted on February 5, 2014 and was discharged on September 30, 2016. A treatment plan update was due no later than October 13, 2015; however, the update was not completed until March 31, 2016.
Patient #9 was admitted on October 16, 2012 and was an active patient at the time of the inspection. A treatment plan update was due to be completed by October 21, 2015 and the next update was not completed until February 9, 2016. The following treatment plan update was not completed until April 22, 2016.
Patient #10 was admitted on June 21, 2012 and was an active patient at the time of the inspection. A treatment plan update was due to be completed by October 14, 2015 and the next update was not completed until February 19, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A thorough review of Pt. engagement and services rendered with the Center Director, Clinical Supervisor and the Clinical Team has commenced as of October 14, 2016 in response to the comments noted to 709.92(b). Based on existing staffing at the time in question, there had been significant staffing pattern changes and adjustments made during the time period in question; as noted and reviewed during this audit and exit; in order to address the same. Dunmore CTC being re-staffed fully as of September 21, 2016, along with on-going weekly Clinical Team meetings and tracking mechanisms being placed into action as a result of these findings, it is expected that such matters will be corrected. On-going meetings with the Center Director & Clinical Supervisor, along with the Regional Clinical Services Coordinator will ensure compliance to the same moving forward. A review of the progress to this end will be completed on November 30, 2016 with the anticipation of observable corrective trending.
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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 ten patient records, the facility failed to provide a complete patient record in patient records #4, 6, and 7.
Patient #4 was admitted on April 14, 2015 and was discharged on August 25, 2016. The patient record did not contain a discharge summary or any documentation of follow-up information as of the date of the inspection.
Patient #6 was admitted on February 5, 2014 and was discharged on September 30, 2016. The patient record did not contain any documentation of follow-up information as of the date of the inspection.
Patient #7 was admitted on February 4, 2016 and was discharged on July 28, 2016. The patient record did not contain a discharge summary or documentation of case consultation as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A thorough review of Pt. engagement and services rendered with the Center Director, Clinical Supervisor and the Clinical Team has commenced as of October 14, 2016 in response to the comments noted to 709.93(a). Based on existing staffing at the time in question, there had been significant staffing pattern changes and adjustments made during the time period in question; as noted and reviewed during this audit and exit; in order to address the same. Dunmore CTC being re-staffed fully as of September 21, 2016, along with on-going weekly Clinical Team meetings and tracking mechanisms being placed into action as a result of these findings, it is expected that such matters will be corrected. On-going meetings with the Center Director & Clinical Supervisor, along with the Regional Clinical Services Coordinator will ensure compliance to the same moving forward. A review of the progress to this end will be completed on November 30, 2016 with the anticipation of observable corrective trending.
Pursuant to the ongoing reviews, the Clinical Supervisor will continue to conduct weekly and monthly reviews of all services necessary; including case consults. Additionally, the CS will conduct a review of post treatment documentation such as discharge summaries and follow-up contacts. The former will be assigned to the active PC in question. As was the case with in-completed discharge summaries during this audit period, if the staff member is no longer employed, the CS will make notation to such and notation to close out the discharge summary with as much detail and information that may be gleaned from their interactions with Pt., as may be ascertained from the Pt. record and in consult with the Multi-Disciplinary Team members.
As to the latter, Follow up contacts will be assigned by the CS to either the primary clinician and/or the Admissions team; these contacts to be documented with the EHR and noted accordingly.
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