INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 4, 2021 through March 5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client # 1 was admitted on October 1, 2019 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client and witness on October 1, 2019 and it expired on October 1, 2020. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after October 1, 2020.
Client # 2 was admitted on April 27, 2020 and was discharged on November 12, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Addressing Confidentiality Deficiency 709.28, failure to obtain proper consent from client for disclosure of information. Client #1 has signed a current consent to release information to her funding source. Client #2 is no longer a patient at this facility and deficiency cannot be corrected. To address this issue, a clinical meeting will be held on March 30 with the whole clinical staff to review the proper procedures for completing an informed consent to release client information. This will be held by the Clinical Supervisor and monitored in chart audits by the clinical supervisor and the lead counselor in supervision. Program Director will oversee this process. Time for Completion: March 30, 2021 |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review client records, the facility failed to document the specific information to be disclosed on release of information forms in one of seven client records reviewed.
Client # 2 was admitted on April 27, 2020 and was discharged on November 12, 2020. The release of information forms to medical providers and a social service agency were signed and dated by the client on May 5, 2020, but they did not document the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Addressing Confidentiality Deficiency 709.28, failure to obtain proper consent from client for disclosure of information. Client #1 has signed a current consent to release information to her funding source. Client #2 is no longer a patient at this facility and deficiency cannot be corrected. To address this issue, a clinical meeting will be held on March 30 with the whole clinical staff to review the proper procedures for completing an informed consent to release client information. This will be held by the Clinical Supervisor and monitored in chart audits by the clinical supervisor and the lead counselor in supervision. Program Director will oversee this process. Time for Completion: March 30, 2021 |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 6 was admitted on October 19, 2019 and was administratively discharged on February 11, 2020. There was no documentation in the client record indicating that the client was given the opportunity to request reconsideration of the decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to address this deficiency, program termination policy has been revised to state that all involuntary terminations will be given the opportunity to request reconsideration of the decision to terminate treatment for at least 7 days. The Program Director will be responsible to communicate this opportunity with the patient in writing and delivered by mail if necessary. Time for Completion: Immediately |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's January 2019 through February 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following the physical assault involving clients at the facility on the following dates:
April 27, 2019; September 17, 2019; October 12, 2019; and January 27, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility had misinterpreted this standard and program director was only reporting deaths to the department. For all future incidents, facility will report the mandated incidents within 3 days of occurrence. The program director will be responsible for the submission of these reports. This will be corrected immediately. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's January 2019 through February 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on the following dates:
February 25, 2019; April 17, 2019; May 14, 2019; August 9, 2019; August 11, 2019; August 27, 2019; September 18, 2019; March 6, 2020; July 22, 2020; September 9, 2020; September 15, 2020; October 23, 2020; December 30, 2020; and February 17, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility had misinterpreted this standard and program director was only reporting deaths to the department. For all future incidents, facility will report the mandated incidents within 3 days of occurrence. The program director will be responsible for the submission of these reports. This will be corrected immediately. |
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 an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in three of five applicable patient records reviewed.
Patient # 1 was admitted on October 1, 2019 and was still active at the time of the inspection. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:
- January 2021 - 1 hour documented
- December 2020 - 1 hour documented
- November 2020 - 45 minutes documented
- October 2020 - 1 hour documented
- September 2020 - 1 hour and 15 minutes documented
Patient # 2 was admitted on April 27, 2020 and was discharged on November 12, 2020. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:
- October 2020 - 45 minutes documented
- June 2020 - 1 hour documented
- May 2020 - 1 hour documented
Patient # 3 was admitted on May 14, 2020 and was still active at the time of the inspection. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:
- February 2021 - 1 hour and 30 minutes documented
- January 2021 - 30 minutes documented
- December 2020 - 30 minutes documented
- November 2020 - 30 minutes documented
- October 2020 - 30 minutes documented
- September 2020 - 30 minutes documented
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per this deficiency, program has struggled to make the mandated 2.5 hours due to COVID restrictions and telehealth. Program has requested a back to work permission to corporate so the counselors may have access to the patients who come daily to the clinic. Counselors have struggled to get patients to do zoom meetings, answering their phones and keeping them on the phone long enough to do a session. In order to try to correct this problem, the program is making use of alerts to patients and having them call their counselors from the clinic prior to getting medicated. This problem should be corrected fully when counselors are given permission to come back to work at the clinic. In the event that the counselors are not permitted to come back to the clinic we are putting other measures in order to engage our patients for 2.5 hrs. we have ordered additional computer to be put in a private room and patients will need to use them to do zoom meetings with their counselors prior to dosing when they are non compliant. we have also had our patients sign contract letters showing that is their responsibility as well to do 2.5 hours of minimum services per month. Clinical Meeting of 3/30/21 will also address the counselors need to maintain this compliance. a report will be run weekly by the Clinical Supervisor to show this compliance and need for further intervention when necessary. Program Director will oversee this project. |