INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 9 to 10, 2012, licensure renewal inspection. The follow-up inspection was conducted on July 18, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations in two of six personnel records.
The findings include:
Six personnel records were reviewed on January 9, 2012. All six personnel records were required to include documentation of annual performance evaluations. Two of six personnel records had no documented annual performance evaluations, # 3 and 5.
Personnel record # 3 had a documented annual performance evaluation dated and signed on 9/2/10. Another document of performance review was signed. A date of signature was not included to verify completion date.
Personnel record # 5 had a documented annual performance evaluation of 9/7/10.
The findings were reviewed with the facility director and clinical supervisor.
This was still out of compliance at the time of the follow-up conducted on July 18, 2012.
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Plan of Correction
MCMC policy is that all employees shall receive an annual evaluation of performance. This is the responsibility of the supervisors of each department and the program director. The Program Director will ensure that this is done on an annual basis and monitor for completeness. |
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 the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in three of eight records.
The findings included:
Eight client records were reviewed on July 18, 2012. The facility failed to ensure that an informed and voluntary consent to release information was obtained in three of eight records, # 1, 2, and 8.
A review of patient record # 1 revealed information was released to a funding source on 2/21/2012 and the consent was signed on 2/22/2012.
A review of client record # 2 revealed information was released to a treatment provider without a documented consent on 5/21/2012. In addition, the release did not have a witness signature and date.
A review of client record # 8 revealed a consent to release information was signed on 5/3/2012 for the health department that failed to specify the information to be released and the purpose for the disclosure on the consent form. On 7/18/2012 a progress note stated the "(p)atient asked counselor if she could write a letter to her PO confirming she is in treatment at MCMC." A letter dated July 18, 2012, was reviewed and found to be inclusive of information beyond the scope of 4 Pa. Code 255.5 particularly the recommendations for treatment attendance and the listing of medication by name.
The findings were reviewed with the facility director and clinical supervisor.
This is a repeat citation from the annual licensing inspection conducted on January 9 to 10, 2012.
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Plan of Correction
A Clinical Meeting has been held by the clinical supervisorwith the clinical staff to review 4 PA Code 255.5 regarding the need to obtain an informed and voluntary written consent for the disclosure of information contained in the client record in writing prior to releasing confidential information. No information shall be disclosed without such written consent. Clinical Supervisor will monitor for compliance to this policy and Program Director will oversee this compliance. Completed 8/30/12 |
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 client records, the facility failed to document a psychosocial evaluation according to policy in two of five records.
The findings include:
Eight patient records were reviewed on July 18, 2012. Five patient records were reviewed for documentation of a psychosocial evaluation. Two of five records had psychosocial evaluations completed outside of the policy time frame. The facility policy is completion of the psychosocial evaluation will be completed at intake. The facility failed to document a psychosocial evaluation according to facility policy in patient records # 6 and 7.
Patient # 6 was admitted to the program on April 4, 2012. The psychosocial evaluation was signed and dated on June 25, 2012, over 2 months after entering treatment. The psychosocial evaluation failed to include a clinical assessment of client problems/needs and support systems.
Patient # 7 was admitted to the program on April 13, 2012. The psychosocial evaluation was documented and signed on June 8, 2012 almost 2 months after entering treatment. The psychosocial evaluation failed to include a clinical assessment of support systems.
The findings were reviewed with the facility director and clinical supervisor.
This is a repeat citation from the annual licensing inspection conducted on January 9 to 10, 2012.
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Plan of Correction
A Clinical Meeting has been held by the clinical supervisorwith the clinical staff to review MCMC policy as to time frames and completion of psychosocial evaluations. Clinical Supervisor will monitor for compliance to this policy and Program Director will oversee this compliance. Completed 8/30/12 |
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 patient records, the facility failed to document treatment plan updates in five of seven patient records.
The findings include:
Eight patient records were reviewed on July 18, 2012. Seven patient records were reviewed for treatment and rehabilitation plan updates. These are to be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in patient records # 1, 2, 4, 5 and 7.
Patient # 1 was admitted on February 22, 2012, and discharged on July 5, 2012. A treatment plan update was signed at discharge by staff in July 2012. It was not signed or dated by the patient. A treatment plan update was due in May 2012.
Patient # 2 was admitted on March 27, 2012, and discharged on July 16, 2012. A treatment plan update was due in May 2012. A treatment plan update was not documented in the record at the time of the review.
Patient # 4 was admitted on April 21, 2011, and discharged on July 6, 2012. A treatment plan update was signed by staff on March 29, 2012, with a patient signature without a date. A treatment plan update for May 30, 2012, stated the patient was "unavailable to sign." There were no further treatment plan updates documented in the record.
Patient # 5 was admitted on February 24, 2011, and discharged on June 5, 2012. A treatment plan update was signed by staff on April 6, 2012, with a patient signature without a date. A treatment plan update for May 15, 2012, stated "did not obtain signature" regarding the patient's signature. There were no further treatment plan updates documented in the record.
Patient # 7 was admitted on April 13, 2012. A comprehensive treatment plan was signed and dated May 11, 2012, by the patient. At that time, the patient was incarcerated. There were no treatment plan updates documented in the record.
The findings were reviewed with the facility director and clinical supervisor.
This is a repeat citation from the annual licensing inspection conducted on January 9 to 10, 2012.
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Plan of Correction
A clinical meeting was held by the Clinical Supervisor on August 13, 2012 to address various clinical issues including treatment planning and the need to do treatment planning updates every 60 days to reflect client goals, objectives, time frames, etc. and these plans are to be developed with the patient and appropriately signed and dated by the patient and documented that this has been done. Clinical Supervisor will monitor for completeness and Program Director will oversee this compliance. Completed 8/13/12 |