INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on June 8, 2022 through June 9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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(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 personnel records and the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health-related topics training within the regulatory time frame in one of six applicable personnel records reviewed.
Employee #5 was hired as a counselor on February 21, 2021. The HIV/AIDS and the TB/STD trainings were due no later than February 21, 2022. However, neither training was completed as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff will be asked from hire to submit any certificates for required trainings to their supervisor. The supervisor will assess training needs with the individual and develop a training plan within the first 90 days of employment. Any required trainings will be scheduled as soon as possible. Director will inform management of this plan during the July 13th QI/management meeting and monitor for ongoing compliance as they are filed within personnel charts. The individual in question has completed both trainings (6 hrs of HIV 6/10/22 and 4 hrs of TB/STD/Hepatitis 6/17/22) at the time of this plan of correction. |
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 of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed. Additionally, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in one of seven client records reviewed.
Client # 1 was admitted on September 13, 2021 and was still active at the time of the inspection. There were release of information forms to a funding source and a laboratory, signed and dated by the client and witness on September 13, 2021, but neither release form documented the specific information to be disclosed.
Client # 6 was admitted on March 22, 2016 and was discharged on May 5, 2022. The release of information form to a funding source was signed and dated by the client on March 31, 2022 and allowed for the release of the clients " methadone dose level " and " lab and UDS results " , all of which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the July 29, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Releases for necessary stakeholders such as laboratory's and funders have templates in the electronic health record that are compliant with regulations. Program Director will review confidentiality regulations and use of templates and releases during staff meeting on June 28, 2022. Since this is a repeat citation, a refresher confidentiality course will be required of all staff in the 2022/2023 training plan. Counselors will continue to do periodic reviews of client charts for compliance for releases of information. Clinical supervisors then review chart audits in monthly supervisions. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete and document a random urinalysis, for each patient, at least monthly in three of seven patient records reviewed.
Patient #3 was admitted into the outpatient maintenance activity on September 18, 2018 and was active at the time of inspection. There was no documentation that a random urinalysis was conducted for the month of March 2022.
Patient #5 was admitted into the outpatient maintenance activity on February 5, 2015 and was discharged April 4, 2022. There was no documentation that a random urinalysis was conducted for the month of March 2022.
Patient #6 was admitted into the outpatient maintenance activity on March 22, 2016 and was discharged on May 5, 2022. There was no documentation that a random urinalysis was conducted for the months of February 2022 and March 2022.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Urine drug screens are randomly generated through our electronic health record. However, two glitches were identified as a result of the audit. The first glitch was the inability of the EHR system to recognize/separate a pregnancy test from a drug screen. The second is the ability of the EHR to identify and request a urine when someone is suspended or absent for over 30 days. Moving forward to address the initial glitch, any patient given a pregnancy test, will also be given a urine drug screen simultaneously. Also for the second glitch, the clinical supervisor and physician assistant will review the suspension and dosing lists at least monthly to identify any patient that may be temporarily suspended or at a zero dose of methadone which may result in a urine drug screen not being generated or collected. Any individual identified as "at risk" for not providing a urine will have a plan developed based on their current treatment status and prognosis. The program director will make this plan known to all staff at the weekly staff meeting July 13, 2022 as well as provide support and oversight in individual plan development. |