INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 1, an abbreviated off-site inspection, conducted on June 4, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to provide documentation that an individual training plan, for the current training year, was developed with input from both the employee and the supervisor, in 1 of 10 personnel records reviewed.
Employee # 2 was hired as the Facility Director on October 2, 2006. The training plan signed by the employee on July 1, 2019 failed to include the supervisor's signature.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As per 704.11,Staff development plan , a written training plan should be developed with each employee annually. This did not happen in one of 10 records. The training plan developed was not signed by a supervisor. Going forward, all training plans for EE#2 will be the responsibility of the Regional Director and Assistant Regional Director who will ensure that this plan is implemented and that steps are taken to ensure that this deficiency does not recur. FY 20/21 plan will be developed with the EE and the Assistant Regional Director by 7/15/2020 |
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.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that three of seven applicable employees reviewed received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD training within the regulatory timeframe.
Employee # 4 was hired as a counselor on May 29, 2018 and was due to have HIV/AIDS training and TB/STD training no later than May 29, 2019. The TB/STD training was completed late on March 9, 2020 and there was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 6 was hired as a counselor on May 28, 2019 and was due to have HIV/AIDS training and TB/STD training no later than May 28, 2020; however, there was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
Employee # 7 was hired as a counselor on May 28, 2019 and was due to have HIV/AIDS training and TB/STD training no later than May 28, 2020; however, there was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
As per 704.11 (c) (1), staff requirements to have 6 hrs HIV and 4 Hrs TB/STD trainings within the first year of hire, MCRC was out of compliance with 3 staff not completing this requirement. All three staff are registered for HIV 6 hour training as of 6/25/2020.These trainings will be completed by 7/15/2020. Supervisors will monitor in the future that these requirements are met for future employees in the first year and that the counselors get the required trainings within that first year. This will be monitored in supervisions and overseen by the the Program Director to ensure compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on the review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's July 1, 2018 through June 30, 2019 training year in one of two applicable employee files.
Employee # 5's personnel file documented only 13 hours of annual training for the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As per regulation 704.11, the requirement that all counselors must have 25 training hours annually, Counselor #5 did not meet this requirement for yr 2018-2019. Counselor #5 will be monitored by her direct supervisor throughout the year to be sure that she is in compliance with this regulation. Her immediate supervisor will be responsible for this compliance and the Program Director will oversee that this deficiency is corrected and ensure it does not happen again. Year 2019-2020 will be completed by 6/30/2020. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that three of ten counselors did not exceed the outpatient 35 to 1 counselor to client ratio.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 6 was hired as a counselor on May 28, 2019. The ratio calculation was as follows: 40/40 = 1(FTE); 36/1 = 36, which equals to a client/counselor ratio of 36:1.
Employee # 7 was hired as a counselor on May 28, 2019. The ratio calculation was as follows: 40/40 = 1(FTE); 37/1 = 37, which equals to a client/counselor ratio of 37:1.
Employee # 12 was hired as a counselor on June 20, 2016. The ratio calculation was as follows: 0/40 = 0.25(FTE); 10/0.25 = 40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As per regulation 704.12 regarding counselor outpatient FTE ratios, EE #6, #7,#12 exceeded the max of 35:1. As of this date, current counselor caseloads have been adjusted and are in compliance with the 35:1 ration. By 7/30/2020, MCRC will have looked at all staffing patterns and anticipates adding a FT counselor position to remain in compliance with this regulation. Program Director will oversee this and ensure ongoing compliance with this reg. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on the administrative review of the August 2018 through April 2020 fire drill logs, the facility failed to document if the smoke detector or fire alarm was operative during the monthly fire drills conducted in January, February, April, May June, July, August, September, October, November and December 2019, as well as January and February 2020.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As per 705.28 (d) (4) Fire Safety, MCRC failed to provide documentation several months regarding the operation of the smoke alarms and smoke detectors. It was discovered that we were using 2 different forms and on did not have the required check list. Our Property Manager and I have developed a new form that is CARF compliant and will ensure that this does not happen again. Our Property Manager will continue to complete the actual drills and the form and the Program Director will sign and check to ensure compliance. Completed 6/12/2020 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on the review of personnel records, the facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation in one of four applicable employee records reviewed.
Employee # 2 was hired as the Facility Director on October 2, 2006. There was no documentation of an annual written individual performance evaluation completed for the 2019 review year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As per 709.26 (b)(3) an annual performance evaluation was not provided as per the regs. An annual evaluation was not provided for Employee #2 for Yr 2019. Previous Assistant Regional Director was responsible to provide this evaluation and will do so by 7/30/2020. Going forward, Regional Director and new Assistant Regional Director will by responsible to provide all future evaluations for EE#2. Program Director will monitor this compliance to ensure this deficiency. New performance evaluation for 2020 will completed by 7/30/2020. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on an administrative review, the facility failed to ensure that narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients. The narcotic treatment physician time sheets were reviewed for the months of January, February, March and April 2020. The following weeks failed to be in compliance:
-During the week of January 1, 2020 to January 5, 2020 the patient census was 333. The facility was required to provide at least 34 physician hours. There were 15 physician hours documented.
-During the week of April 19, 2020 to April 24, 2020 the patient census was 321. The facility was required to provide at least 33 physician hours. There were 27 physician hours documented.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As per 715.6 (d) Physician Staffing, MCMC was out of compliance regarding the number of physician staff hours per census. Program Director, PA C and the medical director will review the census weekly to ensure that this ration is being met. Physician will adjust her hours accordingly with the census. Program Director will oversee this process to ensure compliance. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
|
Observations
Based on an administrative review, the facility failed to insure that at least one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician and that time provided by a physician assistant did not exceed two-thirds of the required narcotic treatment physician time. The narcotic treatment physician and physician assistant time sheets were reviewed for the months of January, February, March and April 2020. The following weeks failed to be in compliance:
-During the week of January 13, 2020 to January 20, 2020 the patient census was 329. The facility was required to provide at least 33 physician hours, of which 11 were to be provided by the physician. There were 10 hours provided by the physician and 32 hours provided by the physician assistant.
-During the week of January 26, 2020 to January 31, 2020 the patient census was 333. The facility was required to provide at least 34 physician hours, of which 12 were to be provided by the physician. There were 9 hours provided by the physician and 31 hours provided by the physician assistant.
-During the week of February 24, 2020 to February 29, 2020 the patient census was 329. The facility was required to provide at least 33 physician hours, of which 11 were to be provided by the physician. There were 10 hours provided by the physician and 32 hours provided by the physician assistant.
-During the week of March 9, 2020 to March 15, 2020 the patient census was 328. The facility was required to provide at least 33 physician hours, of which 11 were to be provided by the physician. There were 9 hours provided by the physician and 31 hours provided by the physician assistant.
-During the week of April 1, 2020 to April 8, 2020 the patient census was 321. The facility was required to provide at least 33 physician hours, of which 11 were to be provided by the physician. There were 6 hours provided by the physician and 30 hours provided by the physician assistant.
-During the week of April 9, 2020 to April 17, 2020 the patient census was 321. The facility was required to provide at least 33 physician hours, of which 11 were to be provided by the physician. There were 6 hours provided by the physician and 38 hours provided by the physician assistant.
-During the week of April 25, 2020 to April 30, 2020 the patient census was 322. The facility was required to provide at least 33 physician hours, of which 11 were to be provided by the physician. There were 9 hours provided by the physician and 30 hours provided by the physician assistant.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As per 715 6 (e) regarding the ratio of Physician to PA C MCMC was out of compliance with the PA C doing more than 2/3 of the time allotted. Medical team and the program director will meet weekly and review the census and the physician and PA C time to correct this problem. Program Director will monitor this and ensure compliance. |