INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2010 through January 7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Montgomery County Methadone Center 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 and a plan of correction is due on February 2, 2010..
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of the facilities staff development documentation, the facility failed to have documented the facilities annual evaluation of the overall training plan for training year July 1, 2008 through June 30, 2009.
The finding includes:
The staff development documentation was reviewed on January 6, 2010 and a interview with the facility director was also conducted on that day. Per the facilities policy and procedure manual reviewed on January 6, 2010 states that the facility director will completed the annual evaluations of the overall training plan at the end of the facilities fiscal year (June 30) by September 1 of each year. The facility director stated that she did not do it.
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Plan of Correction
As per MCMC policy and procedure the Facility Director will set up an annual training plan along with the Clinical Supervisor as part of the staff development program and the facility Director will do an annual evaluation of the prior year training plan no later than 9/1. Clinical Supervisor will review this evaluation for compliance and to develope the following year training plan. Time Frame: 9/1/10 |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all bathrooms had ventilation by exhaust fan or window.
The finding includes:
The physical plant inspection took place on January 7, 2010 around 10 AM and an interview was conducted with the facility director on the same day. There are two ladies restrooms, one observation restroom which is unisex and one handicapped restroom. During the inspection, at approximately 10:15 AM, it was observed that the exhaust fan in one of the restrooms was not working. When the facility director was interviewed she responded that she had been unaware of the problem but would contact the landlord in an effort to repair the the exhaust fan.
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Plan of Correction
The exhaust fan in the Ladies Bathroom was replaced on 1/8/10. A facility Property Monitor has been appointed by the Facility Director to inspect the facility monthly for compliance and needed repair. Property Monitor will be monitored by the Facility Director for compliance to standards. Completed 1/8/2010 |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of fiscal documents presented at the time of the inspection and an interview with the facility director, the facility failed to document a finalized annual audit of financial activities for the year.
The findings included:
During the onsite licensing inspection conducted from January 6, 2010 through January 7, 2010 the fiscal documents were reviewed on January 6, 2010. The facility presented a drafted audit which was dated January 6, 2010 for fiscal year July 1, 2008 through June 30, 2009. The drafted audit did not have the name of the accounting firm or the signature from the accountant who conducted the audit. An interview was conducted with the facility director on January 6, 2010 and she informed me that the facility would soon have a finalized copy of the audit.
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Plan of Correction
MCMC Program Director has contacted RHD Corporate Fiscal Officials to advise and ensure that the fiscal audit must be completed no later than 6 months after the close of the books which is no later than 12/30 in the fiscal year. RHD HUB Management will monitor corporate officials for compliance.Time Frame: Completed |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to completely document psychosocial evaluations in six of seven records reviewed.
The finding includes:
Seven records were reviewed on January 7, 2009. Psychosocial evaluations were required in seven records reviewed.
Client record #1 failed to provide documentation the client's support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client record #2 failed to provide documentation of the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the client's attitude toward treatment.
Client record #3 failed to provide documentation of the client's assets and strengths, support systems, coping mechanisms, clients negative factors that might inhibit treatment and the client's attitudes toward treatment.
Client record #4 failed to provide documentation of the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client's attitude toward treatment and the counselor conclusions/impressions.
Client record #5 failed to provide documentation of the client's assets and strengths, support systems, coping mechanisms and the clients negative factors that might inhibit treatment.
Client records #7 failed to provide documentation of the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
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Plan of Correction
A clinical meeting will be held by the clinical supervisor to review and instruct the proper documentation on the psychosocial evaluation regarding support systems, coping mechanisms, negative factors that might impact treatment as well as client's attitude toward treatment. Clinical supervisor will monitor future psychosocial evaluations for complaince. Time Frame: 2/3/10 |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to provide written documentation of the proposed type of support service in the individual treatment and rehabilitation plans, in four of seven client records.
The findings include:
Seven client records were reviewed on January 7, 2009 and a interview with the facility director conducted on the same day. The individual treatment and rehabilitation plans were required to document proposed type of support services in seven client records. The facility did not document the proposed type of support services in client records # 1, 3, 4 and 6.
Client # 1 was admitted on November 19, 2009. The individual treatment and rehabilitation plan was completed on July 5, 2010. There was no documentation of support services in the treatment plan.
Client # 3 was admitted on September 29, 2009. The individual treatment and rehabilitation plan was completed on October 30, 2009. There was no documentation of support services in the treatment plan.
Client #4 was admitted on August 13, 2009. The individual treatment and rehabilitation plan was completed on September 14, 2009. There was no documentation of support services in the treatment plan.
Client #6 was admitted on February 3, 2009. The individual treatment and rehabilitation plan was completed on February 9, 2009. There was no documentation of support services in the treatment plan.
In an interview, he facility director stated that she believe this documentation was being included in the treatment plan and indicated the deficiency would be addressed with staff.
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Plan of Correction
A clinical meeting will be held by the clinical supervisor to review and instruct the proper documentation of support services in the individual treatment and rehabilitation plans in client records.Clinical supervisor will monitor future treatment plans for compliance. Time Frame: 2/3/10 |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in one of two discharge records reviewed.
The finding includes:
Seven client records were reviewed on January 7, 2010. Follow-up information were required in two discharge records, #5 and 6. The facility's policy and procedure stated that follow-up documentation would be documented within 30 days following discharged if not being referred.
Client record #6 was voluntarily discharged on October 19, 2009. As of January 7, 2010, there was no documentation of follow-up information included in record reviewed.
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Plan of Correction
A clinical meeting will be held by the clinical supervisor to instruct regarding clinic policy of the need for 30 day follow up upon discharge and documentation of this follow up. Clinical supervisor will monitor discharge charts for compliance. Time Frame: 2/3/10 |