INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on January 9 to 10, 2012, 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.
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure all fire extinguishers are inspected annually.
The findings include:
A physical plant inspection was conducted on January 10, 2012, from 3:00 p.m. to 3:30 p.m. The fire extinguisher had documentation of an inspection, last dated June 2010.
The fire extinguisher was shown to the facility director who confirmed the findings.
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Plan of Correction
A meeting was held between the Program Director and the MCMC assigned Property Manager to put in place the plan of adding inspection of fire extinuishers to the monthly property and physical plant inspection list to ensure that fire extinguishers are inspected annually and are in compliance with licensure standards. The fire extinguisher that was out of compliance at the time of licensure has since been inspected by the fire extinguisher company and has been brought into compliance with standards. The Program Director will monitor this monthly and sign off to ensure that this will not happen in the future. Completion date: 1/25/12 |
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
Based on a review of the fire drill record log, the facility failed to document two monthly fire drills.
The findings include:
The fire drill record log was reviewed on January 9, 2012. The log was reviewed from January 2011 to December 2011. April 2011 and August 2011 did not document that a fire drill was conducted.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
A meeting was held between the Program Director and the MCMC assigned Property Manager to put in place the practice of performing fire drills monthly without exception and to document these drills as well as which smoke detector was activated to remain in compliance with licensure standards. The Program Director will monitor this monthly and sign off to ensure that this will not happen in the future. Completion date: 1/25/12 |
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
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on January 9, 2012. The fire drill log was reviewed for documentation of fire drills from the time period of January 2011 to December 2011. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for the fire drills documented for March 2011, May 2011, June 2011, July 2011, September 2011, October 2011 and November 2011.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
A meeting was held between the Program Director and the MCMC assigned Property Manager to put in place the practice of performing fire drills monthly without exception and to document these drills as well as which smoke detector was activated to remain in compliance with licensure standards. The Program Director will monitor this monthly and sign off to ensure that this will not happen in the future. Completion date: 1/25/12 |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on observation during the physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.
The findings include:
The physical plant inspection was conducted on January 10, 2012 between 3:00 p.m. and 3:30 p.m. It was observed in the child play area that two electrical outlets failed to have three of four required protective caps.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
A meeting was held between the Program Director and the MCMC assigned Property Manager to put in place the plan of adding inspection of electrical outlets to the monthly property and physical plant inspection list to ensure that electrical outlets are covered in all areas particularly in child play areas and documented on the property inspection form.The Program Director will monitor this monthly and sign off to ensure that all outlets are coveredand this will not happen in the future. Completion date: 1/25/12
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709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based upon a tour of the facility, the facility failed to have the fee schedule posted in a prominent place.
The findings include:
A physical plan tour was conducted on January 10, 2012 at 3:00 p.m. The facility fees were posted in the fiscal office. The facility failed to have the fee schedule posted in a prominent place.
The facility director and clinical supervisor confirmed that the fees were not posted in a prominent place.
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Plan of Correction
Program Director has posted the facility fees in a prominent place in the patient lobby to be highly visible for all to see. Program Director will monitor to ensure that fees remain posted and are not removed from prominent place in lobby.
Completed 1/25/12 |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations in two of six personnel records.
The findings include:
Six personnel records were reviewed on January 9, 2012. All six personnel records were required to include documentation of annual performance evaluations. Two of six personnel records had no documented annual performance evaluations, # 3 and 5.
Personnel record # 3 had a documented annual performance evaluation dated and signed on 9/2/10. Another document of performance review was signed. A date of signature was not included to verify completion date.
Personnel record # 5 had a documented annual performance evaluation of 9/7/10.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
A meeting was held by Program Director with MCMC department supervisors to address the necessity for the documentation of personnel evaluations to be conducted on all employees annually and signed and dated at the time of the evaluation. Program Director will Cosign and monitor to ensure that this oversight does not happen again. The two performance evaluations that were missing at the time of monitoring have been completed.
Completed 1/25/12 |
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 an informed and voluntary consent to release information was obtained in three of ten records.
The findings included:
Ten client records were reviewed January 10, 2012. The facility failed to ensure that an informed and voluntary consent to release information was obtained in three of ten records, # 7, 8, and 10.
A review of patient record # 7 revealed information was released to a funding source without a documented consent on 11/17/2011.
A review of client record # 8 revealed information was released to a funding source without a documented consent on 8/31/2010.
A review of client record # 10 revealed information was released to a funding source without a documented consent on 12/13/2011.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
An Inservice will be held by the Clinical Supervisor and MCMC Staff to address Confidentiality Standards and to review requirements including proper completion of paperwork to ensure that patient confidentiality is protected. Clinical Supervisor will audit counselor charts in individual supervision to ensure that proper documentation is being completed. Program Director will monitor Clinical Supervisor to ensure that this will not happen again in the future. Completion: 2/3/12 |
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 document a psychosocial evaluation according to policy in three of three records.
The findings include:
Ten patient records were reviewed on January 10, 2012. Three patient records were reviewed for documentation of a psychosocial evaluation. Three of three records had psychosocial evaluations completed outside of the policy time frame. The facility policy is completion of the psychosocial evaluation will be completed at intake. The facility failed to document a psychosocial evaluation according to facility policy in patient records # 7, 9, and 10.
Patient # 7 was admitted to the program on 11/15/2011. The psychosocial evaluation was not signed and dated to provide a time frame for completion.
Patient # 9 was admitted to the program on 9/20/2011. The psychosocial evaluation was documented and signed on 12/5/2011.
Patient # 10 was admitted to the program on 12/13/2011. The psychosocial evaluation was not signed and dated to provide a time frame for completion.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
An Inservice will be held by the Clinical Supervisor and MCMC Staff to address the proper completion of the Psychosocial evaluation to ensure that this paperwork is properly completed in the policy time frame, signing and dating and that psychosocial evaluation summaries are a reflection of counselor assessment and evaluation and not just historical data. Clinical Supervisor will audit counselor charts in individual supervision to ensure that proper documentation is being completed. Program Director will monitor Clinical Supervisor to ensure that this will not happen again in the future. Completion: 2/3/12 |
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, the facility failed to document treatment plan updates in one of two patient records.
The findings include:
Ten patient records were reviewed on January 10, 2012. Two patient records were reviewed for treatment and rehabilitation plan updates. These are to be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in patient records # 9.
Patient # 9 was admitted on September 20, 2011. A comprehensive treatment plan was signed and dated by staff on 9/22/2011. It was signed by the patient and not dated. A treatment plan update was signed and dated by staff on 11/28/2011. It was not signed or dated by the patient. A treatment plan update was signed by the counselor and clinical supervisor on 1/9/2012. It was not signed or dated by the patient.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
An inservice will be held by the Clinical Supervisor and with the MCMC Staff to address the treatment planning process to ensure that treatment plans including updates are properly completed in the policy time frame,including proper signing and dating. Clinical Supervisor will audit counselor charts in individual supervision to ensure that proper documentation is being completed. Program Director will monitor Clinical Supervisor to ensure that this will not happen again in the future. Completion: 2/3/12 |