INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on January 22, 2013 to January 23, 2013, 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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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel and training records, the facility failed to document the collection of feedback on completed training in one of two personnel records.
The findings included:
Nine personnel records were reviewed on January 22, 2013. Two personnel records were reviewed for the collection of feedback on completed training. The facility failed to document the collection of feedback in personnel record # 2.
Employee # 2 was hired on October 2, 2006 as the facility director. Feedback on completed training for training year July 1, 2011 to June 30, 2012 was not documented in the personnel record at the time of the review.
The findings were reviewed with the facility director and clinical supervisor and were confirmed.
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Plan of Correction
An inservice meeting has been held by Program Driector and MCMC staff to address the need for documenting feedback on completed trainings. The administrative assistant will collect this information and log into staff development sheet and program director will then receive these documents, review and then file them in personnel charts. PD will monitor for completeness. Date completed 2/19/2013 |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document an individual training plan in one of nine personnel records.
The findings included:
Nine personnel records were reviewed on January 22, 2013. All personnel records were reviewed for an individual training plan. The facility failed to document an individual training plan in personnel record # 5.
Employee # 5 was hired on September 4, 2012 as a counselor. The individual training plan was signed by the employee and the supervisor with a typed date of August 12, 2012 which was prior to the date of hire.
The findings were reviewed with the facility director and clinical supervisor and were confirmed.
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Plan of Correction
A meeting has been held between the Clinical Supervisor and the Program Director to reinforce the policy of MCMC regarding the proper documentation and dating of the staff individual training plans that sre done annually at the beginning of the new fiscal year. Program Director will monitor for compliance. Completed 2/20/13 |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel and training records, the facility failed to document the instruction of staff in the use of fire extinguishers upon employment in two of four personnel records.
The findings included:
Nine personnel records were reviewed on January 22, 2013. Four personnel and training records were reviewed for documentation of staff instruction in the use of the fire extinguisher upon employment. The facility failed to document staff instruction in personnel records # 4 and 5.
Employee # 4 was hired on June 5, 2012 as a counselor. Fire extinguisher instruction was not documented in the personnel record at the time of the review.
Employee # 5 was hired on September 4, 2012 as a counselor. Fire extinguisher instruction was not documented in the personnel record at the time of the review.
The findings were reviewed with the facility director and were confirmed.
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Plan of Correction
A meeting was held by MCMC Fire Marshall D.B. and the MCMC Staff to instruct staff on the use of the fire extinguishers and staff has documented this instruction. Documentation has been reviewed and placed in staff personnel charts. Fire Marshall will conduct this instruction for all new hires and document this instruction. Program Director will also sign this documentation and monitor for completion.Date of Meeting 2/20/2013 |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel and training records, the facility failed to document the training of personnel to perform assigned tasks during emergencies in two of four personnel records.
The findings included:
Nine personnel records were reviewed on January 22, 2013. Four personnel and training records were reviewed for documentation of the training for personnel to perform assigned tasks during emergencies. The facility failed to document notification in personnel records # 4 and 5.
Employee # 4 was hired on June 5, 2012 as a counselor. Training of assigned tasks during emergencies was not documented in the personnel record at the time of the review.
Employee # 5 was hired on September 4, 2012 as a counselor. Training of assigned tasks during emergencies was not documented in the personnel record at the time of the review.
The findings were reviewed with the facility director and were confirmed.
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Plan of Correction
A meeting was held by MCMC Fire Marshall D.B. and the MCMC Staff to instruct staff regarding emergency procedures and training of personnel to perform assigned tasks during emergencies. This training has been documented and reviewed by Program Director and is maintained in personnel charts. All new MCMC employees will be instructed in these procedures at the time of hire by the Fire Marshall and documented and maintained in their personnel charts. All documentation will be reviewed for completeness and signed by the program Director. PD will oversee this project for compliance. Completed 2/19/13 |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedure manual and administrative records, the facility failed to document the project director's annual update of a written manual delineating project polices and procedures.
The findings include:
The policy and procedure manual and administrative records were reviewed on January 22, 2013. The facility provided documentation of the governing body having approved the policy and procedure manual on June 30, 2012 by the secretary of the board. The facility was unable to provide documentation of the project director's annual update of the manual for fiscal year July 1, 2012 to June 30, 2013 at the time of the review.
The findings were reviewed with the facility director and clinical supervisor and were confirmed.
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Plan of Correction
A meeting was held between the MCMC Program Director and the RHD Hub Management on 2/25/13 to ensure that the Project Director provides documentation of the Project Director's annual update of the P&P manual for each fiscal year.Hub Manager will revise existing form to include signature line for Project Director that will document Project Director's update delineating project policies. Program Director will oversee this project and Hub Manager will oversee Project Director for compliance. Date for Completion 4/1/13 |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of the policy and procedure manual and administrative records, the facility failed to document annual goals and objectives for the current fiscal year.
The findings include:
The policy and procedure manual and administrative records were reviewed on January 22, 2013. The facility was unable to provide documentation of the project director and the governing body formulating annual goals and objectives for the fiscal year which began on July 1, 2012.
The findings were reviewed with the facility director and clinical supervisor and were confirmed.
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Plan of Correction
A meeting was held between the MCMC Program Director and the RHD Hub Management on 2/25/13 to ensure that the Project Director provides documentation of the Project Director and the Governing Body formulating annual goals for the Project's fiscal year.Hub Manager will revise existing form to include signature line for Project Director that will document Project Director's formulation of such goals and objectives. Program Director will oversee this project and Hub Manager will oversee Project Director for compliance. Date for Completion 4/1/13 |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide results of reference checks in two of four personnel records.
The findings included:
Nine personnel records were reviewed on January 22, 2013. Four personnel records were reviewed for reference results. The facility failed to document the results of reference checks in personnel records # 3 and 5.
Employee # 3 was hired on January 2, 2013 as a clinical supervisor. The results of reference checks were not documented in the personnel record at the time of the review.
Employee # 5 was hired on September 4, 2012 as a counselor. The results of reference checks were not documented in the personnel record at the time of the review.
The findings were reviewed with the facility director and clinical supervisor and were confirmed.
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Plan of Correction
MCMC Program Director will conduct and document at least (3) references for all future hires at MCMC. These references will be maintained in the personnel files of new hires and Program Director will be responsible for completeness.Effective Immediately. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records, the facility failed to document the project's efforts toward informing employees of his/her rights in three of four personnel records.
The findings included:
Nine personnel records were reviewed on January 22, 2013. Four personnel records were reviewed for documentation of employee notification of his/her rights. The facility failed to document notification in personnel records # 3, 4 and 5.
Employee # 3 was hired on January 2, 2013 as a clinical supervisor. Notification of employee rights was not documented in the personnel record at the time of the review.
Employee # 4 was hired on June 5, 2012 as a counselor. Notification of employee rights was not documented in the personnel record at the time of the review.
Employee # 5 was hired on September 4, 2012 as a counselor. Notification of employee rights was not documented in the personnel record at the time of the review.
The findings were reviewed with the facility director and clinical supervisor and were confirmed.
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Plan of Correction
MCMC Program Director has held a meeting with MCMC staff and reviewed the employee rights and all current employees have signed these rights and all future employees will be given these rights and documentation will be placed in personnel charts. PD will be responsible for this project. Completed 2/19/13 |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in one of five personnel records.
The findings include:
Nine personnel records were reviewed on January 22, 2013. Five personnel records were reviewed for documentation of written job descriptions. The facility failed to obtain the required documentation of a signed job description in personnel record # 5.
Employee # 5 was hired on September 4, 2012 as a counselor. A signed job description was not documented in the personnel record at the time of the review.
The findings were reviewed with the facility director and clinical supervisor and were confirmed.
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Plan of Correction
MCMC Program Director has held a meeting with MCMC staff and reviewed the employee updated job descriptions and all staff has signed documentation and this will be placed in personnel charts. PD will be responsible for the signing of this document by all new hires in the future. PD will be responsible for this project. Completed 2/19/13 |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to secure patient records within locked storage containers.
The findings include:
A physical plant inspection was completed on January 23, 2013. At 9:35 a.m. the file room doors were observed open and the cabinets were unlocked. The patient waiting area is located next to the file room and was occupied with patients in line for medication at the time of the observation.
The open storage area was inspected with the clinical supervisor who confirmed the client records were not secured.
In addition, a personnel record, # 4, contained full names of patients on documents entitled "Services Due by Counselor" and "Unfinished Notes." A patient record, # 1, contained a listing of full names of other patients attached to the discharge summary entitled "County Clients."
The findings were reviewed and confirmed with the facility director and clinical supervisor.
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Plan of Correction
MCMC Program Director has held a meeting with MCMC staff and reviewed regulations regarding confidentiality and the need for all file room doors and cabinets to be secured from patient view at all times. New locks will be installed to install this security and keys issued to staff so doors will not remain open during client attendance hours. Program Director and Clinical Supervisor will also ensure that client names and Lists will not be included in any staff personnel records in the future and will check each other on this issue. Date for completion of locks set for 3/20/13 |
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 a review of patient records, the facility exceeded 4 Pa. Code, Subsection 255.5(b) in one of four records reviewed.
The findings included:
Eight patient records were reviewed on January 23, 2013. Four records were reviewed regarding release of information documentation.
A review of patient record # 4 revealed information was released to children and youth on September 28, 2012. The facility exceeded 4 Pa. Code, Subsection 255.5(b) by releasing information to children and youth that included information on prescription medication. Additionally, information was released to children and youth on October 2, 2012, regarding the nature of the discharge of the patient.
The findings were reviewed and confirmed with the facility director and clinical supervisor.
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Plan of Correction
A Clinical Meeting will be held on 2/22/13 by the Clinical Supervisor and the clinical staff to review the 4 PA Code Subsection 255.5 regarding the release of confidential information going outside the scope of the code. CS will monitor all communications with outside agencies in the future and PD will oversee this project. Date for completion- 2/22/13 |
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 patient records, the facility failed to provide a psychosocial evaluation to include client problems/needs, assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the patient in one of two patient records.
The findings include:
Eight patient records were reviewed on January 23, 2013. Two records were reviewed for a psychosocial evaluation.
Patient # 6 was admitted on September 18, 2012. The psychosocial evaluation did not include an evaluation of the patient's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors and how they would impact treatment.
The findings were reviewed and confirmed with the facility director and clinical supervisor.
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Plan of Correction
A Clinical Meeting will be held on 2/22/13 by the Clinical Supervisor and the clinical staff to review the psychosocial evaluation assessment and proper completion of this document to include client problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and time frames for the completion of this document. CS will monitor ongoing for completion and Prgram Director will oversee this project. Date for Completion 2/22/13 |
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 patient records, the facility failed to document the provision of treatment services consistent with the type and frequency specified in the treatment plan in two of two patient records.
The findings included:
Eight patient records were reviewed on January 23, 2013. Two records were reviewed for documentation of the provision of services in accordance with those specified in the treatment plan. Services were not documented as stated in the treatment plans in records # 6 and 8.
Patient # 6 was admitted on September 18, 2012. The comprehensive treatment plan identified individual and group services to be provided on a weekly basis. The patient record documented an individual session during September 2012. During October 2012, no individual sessions and one group session were documented. In November 2012, an individual session and two group sessions were documented. In December 2012, one group session was documented.
Patient # 8 was admitted on October 18, 2012. The comprehensive treatment plan identified individual and group services to be provided on a weekly basis. The patient record documented an individual session during October 2012. In November 2012, two individual sessions were documented.
The findings were reviewed and confirmed with the facility director and clinical supervisor.
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Plan of Correction
A Clinical Meeting will be held on 2/22/13 by the Clinical Supervisor and the clinical staff to review the need to provide and document services consistent with the type and frequency specified in the patient's individual treatment plan. CS will monitor this compliance ongoing and and PD will oversee this project. Date for completion- 2/22/13
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document an aftercare plan in one of two patient records.
The findings included:
Eight patient records were reviewed on January 23, 2013. Two records were reviewed for documentation of an aftercare plan.
Patient # 3 was admitted on March 29, 2007 and discharged on August 31, 2012. The patient was identified as successfully completing treatment. An aftercare plan is to be completed at discharge. A progress note documented an aftercare plan was reviewed with the patient, however, no aftercare plan could be presented for review of the components required.
The findings were reviewed with the facility director and clinical supervisor and confirmed.
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Plan of Correction
A Clinical Meeting will be held on 2/22/13 by the Clinical Supervisor and the clinical staff to review Aftercare Plans and documentation of these plans to be placed in patient charts. CS will monitor this compliance ongoing and and PD will oversee this project. Date for completion- 2/22/13
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document discharge summaries that included all of the components in two of five patient records reviewed.
The findings included:
Eight patient records were reviewed on January 23, 2013. Five records were reviewed for discharge summaries. Two records were missing components of the discharge summary, # 2 and 3.
Patient # 2 was admitted on July 26, 1991 and discharged on November 2, 2012. The record did not include medication as a service offered by the facility. As this facility is a narcotic treatment program, the medication is a significant component of the treatment services offered.
Patient # 3 was admitted on March 29, 2007 and discharged on August 31, 2012. The record did not include medication as a service offered by the facility. As this facility is a narcotic treatment program, the medication is a significant component of the treatment services offered.
The findings were reviewed with the facility director and clinical supervisor and confirmed.
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Plan of Correction
A Clinical Meeting will be held on 2/22/13 by the Clinical Supervisor and the clinical staff to review discharge summaries and the need for completed documentation of all services offered including medication monitoring as part of an NTP. CS will monitor ongoing for completion and Program Director will oversee this project. Date for Completion 2/22/13 |