INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5, 2008 through February 7, 2008 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 March 5, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document the core curriculum training in clinical supervision for one employee with less than 2 years of supervisory experience, #3.
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Plan of Correction
The Clinical Supervisor is attending the core curriculum in clinical supervision provided by the Department of Health on 3/3/08 to 3/7/08, to fulfill 704.6 requirements. The Program Director shall ensure that all future Clinical Supervisors will attend the Core Curriculum in the mandated timeframe and proper documentation for training will be obtained. |
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 training records, the facility failed to document an individual training plan in one of seven records reviewed, #1.
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Plan of Correction
To fulfill the Department of Health Staff Development Program 704.11(b)(1) requirements, The Program Director shall hold a training with the Clinical Supervisor to review documentation for individual training plans to ensure that each plan is appropriate to that employee's skill level, and is developed with input from both the employee and the supervisor and to ensure that all future employees shall have a documented individual training plan. |
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 training records, the facility failed to document HIV/AIDS and TB/STD training in one of seven records reviewed, #7. Employee #7 was hired 7/25/05.
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Plan of Correction
Meeting will be held between the Clinical Supervisor and The Program Director to ensure that all present and future employees will attend the required HIV/Aids and TB/STD training in the proper time frames and that this shall be documented accordingly by the Clinical Supervisor and Monitored by the Program Director in the staff personnel charts. This meeting will be held by April 1, 2008. This is being resubmitted March 25, 2008 for approval. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to conduct fire drills at different times of the day and on different staffing shifts from August 2007 through January 2008. All fire drills were conducted between 1:00 PM and 4:15 PM.
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Plan of Correction
The Program Director will train the employee designated to conduct the fire drills on proper fire drill procedures for the nonresidential facility per requirements 705.28(d)(6). The designated employee will be instructed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. Fire drills will be conducted at times other than 1:00pm to 4:15pm. The Clinical Supervisor will ensure proper completion of 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
Based on a review of the fire drill record, the facility failed to set off a fire alarm or smoke detector during each fire drill from August 2007 through January 2008.
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Plan of Correction
The Program Director will train the employee designated to conduct the fire drills on proper fire drill procedures for the nonresidential facility per requirements 705.28(d)(7). The designated employee will be instructed to set off a fire alarm or smoke detector during each fire drill. The Clinical Supervisor will ensure proper completion of the fire drills. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the facility failed to complete an annual report for the July 2006 through June 2007 fiscal year.
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Plan of Correction
The Program Director shall complete an annual report and shall make it available to the public, for for the publicly funded nonresidential facility for the July 2007 through June 2008 fiscal year. The annual report shall fulfill the Department of Health Governing Body 709.22(e) requirement. The Fiscal Manager shall monitor for proper completion. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review of administrative documentation, the facility failed to complete an annual report that included activities and accomplishments for July 2006 through June 2007.
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Plan of Correction
The Program Director shall complete an annual report and shall make it available to the public, for for the publicly funded nonresidential facility for the July 2007 through June 2008 fiscal year. The annual report shall include, but not be limited to, the activities and accomplishments of the preceding year. The annual report shall fulfill the Department of Health Governing Body 709.22(e)(1)requirement. The Fiscal Manager shall monitor for proper completion. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of administrative documentation, the facility failed to complete an annual report that included a financial statement of income and expenses for the July 2006 through June 2007 fiscal year.
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Plan of Correction
The Program Director shall complete an annual report and shall make it available to the public, for for the publicly funded nonresidential facility for the July 2007 through June 2008 fiscal year. The annual report shall include, but not be limited to, a financial statementof income and expenses. The annual report shall fulfill the Department of Health Governing Body 709.22(e)(2) requirement. The Fiscal Manager shall monitor for proper completion. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of administrative documentation, the facility failed to complete an annual report that included a statement disclosing the names of officers, directors and principal shareholders for the July 2006 through June 2007 fiscal year.
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Plan of Correction
The Program Director shall complete an annual report and shall make it available to the public, for for the publicly funded nonresidential facility for the July 2007 through June 2008 fiscal year. The annual report shall include, but not be limited to, a statement disclosing the names of the officers, directors and principal shareholders, where applicable. The annual report shall fulfill the Department of Health Governing Body 709.22(e)(3) requirement. The Fiscal Manager shall monitor for proper completion. |
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 client records, the facility failed to informed clients that a consent to release information form may be verbally revoked in eleven of twelve records reviewed, 1, 2, 3, 4, 5, 6, 8, 9, 10, 11 and 12. The "Medical Emergency Release" form states" ...may withdraw release by submitting a written order".
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Plan of Correction
The Program Director held an inservice training for all staff at the weekly staff meeting on March 4, 2008 regarding the informed and voluntary consent obtained from clients for the disclosure of information contained in the client record. The inservice training addressed the the Consent to Release shall be in writing and also include a notice that the consent to release information may be verbally revoked by the client. All staff signed a new "Code of Ethics" acknowledging the client's rights to verbally revoke consent to release information. The "Medical Emergency Release" form has been corrected and now states, "I understand that I can withdraw this release of information authorization at any point verbally or in writing..." The Program Director will ensure all future employees will be instructed upon hire regarding this issue. This completes the Department of Health Confidentiality requirement 709.28(c). |
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 clients records, the facility failed to document complete psychosocial evaluations in eleven of eleven records reviewed, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. Psychosocial evaluations were more historical rather than evaluative and did not assess the client's problems/needs, negative factors that may inhibit treatment and the client's attitude towards treatment.
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Plan of Correction
To fulfill the Department of Health Intake and Admission 709.91(b)(6) requirements, the Program Director will conduct an in-service training for the Intake Specialist and all clinical staff on proper intake procedures that includes documentation of Psychosocial Evaluations. Psychosocial evaluations will be more evaluative and will assess the client's problems/needs, and negative factors that may inhibit treatment and the client's attitude towards treatment. The Clinical Supervisor will monitor training for proper completion and instruct all future employees upon hire regarding this issue to ensure this does not happen in the future. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document an individualized treatment plan with goals specific to each client's needs in twelve of twelve records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
To fulfill the Department of Health Treatment and Rehabilitation Services 709.92(a)(1) requirements, the Program Director will conduct an in-service training for all clinical staff on proper completion of an individual treatment plan that shall include, but not be limited to, written documentation of short and long term goals for treatment formulated by both staff and client that are specific to each client. The Clinical Supervisor will monitor training for proper completion and instruct all new employees upon hire regarding this issue to ensure that this does not happen in the future. |
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 client records, the facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the treatment plan in six of twelve records reviewed, #1, 2, 8, 9, 10 and 11.
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Plan of Correction
To fulfill the Department of Health Treatment and Rehabilitation Services 709.92(b) requirements, the Program Director will conduct an in-service training for all clinical staff on proper treatment plan updates. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days and should include an assessment of the client's progress in relationship to the stated goals of the treatment plan. The Clinical Supervisor will monitor training for proper completion and instruct all new employees upon hire regarding this issue to ensure that this does not happen in the future. |