INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 11, 2017 through July 12, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that 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 within the regulatory timeframe in 1 of 9 personnel records reviewed.
Employee #9 was hired as a counselor on 11/30/15. Employee #9 was due to complete the required HIV/AIDS and TB/STD trainings no later than 11/30/16. However, the employee did not complete the HIV/AIDS training until 6/30/17 or the TB/STD training until 6/20/17.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As per regulations, the facility will ensure that all future and present staff meet the required minimum hours of HIV/ AIDS TB/STD trainings. This will be put in their training plan upon hire and must be done within the first year of hire. Clinical Supervisors will be responsible for this compliance and Program Director will oversee this project. This will also be addressed at an Inservice meeting on 8/8/17 |
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
A review of the July 2016 through June 2017 fire drill logs was conducted during the onsite inspection. The facility failed to document whether the smoke detector or fire alarm was operative for each month reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The MCMC fire drill log has been revised to include information regarding the operation of the smoke detectors and fire alarms. The MCMC fire Marshall will document this compliance at the time of the drill. Completed 7/31/2017 |
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.
|
Observations
Based on a review of 11 patient records, the facility failed to document a complete and informed and voluntary consent to release information form prior to the disclosure of information in 1 record. Additionally, there were consent to release information forms missing required information in 3 records. Also, the facility failed to keep disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 1 record.
Patient # 2 was admitted on 6/23/16 and was still an active patient at the time of the inspection. The record contained consent to release information forms to multiple outside agencies, all signed on 7/10/17, which did not include the specific information to be disclosed.
Patient # 4 was admitted on 5/4/15 and was discharged on 2/22/17. The record contained documentation of letters sent to four separate judges on 5/3/16, 7/11/17, and 7/18/17 that contained the patient's specific medications, which exceeds 4 Pa. Code 255.5 (b).
Patient # 6 was admitted on 8/6/13 and was discharged on 12/9/16. The record contained a consent to release information form to the emergency contact which was not dated by the patient or witness.
Patient # 10 was admitted on 8/9/16 and was discharged on 3/8/17. The record contained a consent to release information form to an outside individual, which was signed by the patient, but not dated. Additionally, the record contained a letter, dated 9/19/16, to an outside individual with medication information included; however, the patient-signed consent to release information form did not include medication information to be released.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An inservice will be held on 8/8/17 by the clinical supervisor with the entire staff to address the issues of confidentiality established by Pa Code 255.5 and it's limitations. Patient #2 has signed new consents that are in compliance on August 2, 2017.Patients #4,#6 and #10 have been discharged. Clinical Supervisor will monitor for this compliance ongoing. Program Director will oversee this for compliance. Completion Date: 8/8/2017 |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on the review of the facility's unusual incident reports on July 11, 2017, the facility failed to notify the Department within the regulatory timeframe following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reason are:
October 26, 2016 - Police presence onsite
December 3, 2016 - Police presence onsite
March 7, 2017 - Ambulance presence onsite
March 20, 2017 - Ambulance presence onsite
March 21, 2017 - Patient's (offsite) death
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All future mandated incidents will be sent to state within the 3 day timeframes by the Program Director and her assistants in her absence. The Program Director will also be submitting today the missed incident reports that were cited as a deficiency.
|
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.
|
Observations
Based on a review of 10 patient records, the facility failed to ensure documentation of the initial urine drug screen in one patient record and the completion of random urine drug screens at least monthly in 4 patient records.
Patient # 1 was admitted on 9/10/09 and was an active patient at the time of inspection. The record was missing documentation of a random urine drug screen for the month of June 2017.
Patient # 2 was admitted on 6/23/16 and was an active patient at the time of inspection. The record was missing documentation of a random urine drug screen for the month of May 2017.
Patient # 5 was admitted on 11/1/16 and was discharged on 4/7/17. The record was missing documentation of a random urine drug screen for the month of December 2016.
Patient # 9 was admitted on 4/18/17 and was an active patient at the time of inspection. The record was missing documentation of the initial urine drug screen as well as a random urine drug screen for the month of June 2017.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
MCMC will ensure documentation of initial and subsequent urine drug screens in patient charts. Copies of these screens will be received and documented in each patient chart by administrative assistants. Counselors will check their clients charts for this posting and clinical supervisor will monitor for compliance. Program Director will oversee this project. Effective Immediately. |