INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 2016 through July 14, 2016 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:
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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 files, the facility failed to ensure that all staff persons received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in employee #5's personnel record.
Employee #5 was hired as a counselor on 02/23/2015. Employee #5 was due to complete the required TB/STD training no later than February 23, 2016. There was a certificate, dated 11/07/12 & 11/09/12, documenting that the employee completed HIV/AIDS, TB/STD trainings on 11/07/12 and 11/09/12; however, the certificate only documented the training as being 6 hours in length, instead of the 10 hours for the combined training.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
In accordance with standard 704.11,general training requirements, MCMC management staff will ensure that all new hire staff will have the appropriate mandated trainings regarding TB/STD/HIV,trainings within the appropriate timeframes. This policy will be immediately enforced and will be monitored by the Program Director and the Clinical Supervisor for compliance. Employee #5 is scheduled for appropriate TB/STD training on November 18, 2016 at BHTEN. Registration has been confirmed by Program Director. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation, the facility failed to ensure privacy so that counseling sessions could not be heard outside of the counseling room. During the licensing inspection, the Licensing Specialists utilized a room located adjacent to the facility's large group room. On July 13, 2016 and July 14, 2016, at approximately 9:00 am both days, the Licensing Specialists were able to clearly hear the conversations of the group sessions that were being held in the large group room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 705.23 to ensure the confidentiality of both group and individual sessions, MCMC has purchased 6 more white noise machines to make a total of 10. These machines have arrived to MCMC and have been placed outside the session rooms by the MCMC property manager and they are to be used at all times when sessions are being held. Counselors are responsible to be sure these machines are in use during their sessions. Clinical Supervisor and Program Director will monitor compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the staff instruction in the use of a fire extinguisher upon staff employment in personnel record #8.
Employee #8 was hired on 06/28/2016. The staff training was not documented as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In accordance with standard 705.28,fire safety requirements, MCMC management staff will ensure that all new hire staff will have the appropriate mandated trainings regarding fire safety to include the instruction of staff in the use of fire extinguishers upon new staff employment. This instruction shall be documented This policy will be immediately enforced and will be monitored by the Program Director and the Clinical Supervisor for compliance. Employee #8 was trained on Fire Safety procedures on 7/27/2016 and this training was documented and placed in employee's personnel file. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, patient records, #1, 5, and 14 had treatment plan updates completed after the regulatory timeframe. Additionally, patient #8 was missing a treatment plan update as of the date of the inspection.
Patient #1 was admitted on 04/28/2011 and was still an active client at the time of the inspection. There were documented treatment plan updates completed on 07/20/15, 09/23/15, 12/1/15, 01/13/16, 3/22/16, and 06/01/16. All the treatment plan updates, except the treatment plan update dated 01/13/16, were completed after the 60-day regulatory timeframe.
Patient #5 was admitted on 02/26/2015 and was discharged on 04/21/2016. There were documented treatment plan updates completed on 07/28/15, 10/02/15, and 03/08/16. All the treatment plan updates were completed after the 60-day regulatory timeframe.
Patient #8 was admitted on 05/03/2005 and was discharged on 10/21/2015. A treatment plan update was completed on 08/10/15 and the next update was due no later than 10/10/15; however, there was no update documented at the time of the inspection.
Patient #14 was admitted on 10/29/2015 and was discharged on 05/02/2016. A treatment plan update was completed on 01/28/16 and the next update was due no later than 03/28/16; however, the update was not completed until 04/06/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 715.23(d)(2) a clinical meeting was held by the clinical supervisor with MCMC on 7/26/16 to address the need for treatment planning as an essential part of treatment and to address the timeliness of these plans to coincide with this regulation. Updates must be completed within regulatory timeframes and lateness will not be tolerated and cause for disciplinary action. This has also been addressed by the clinical supervisor individually in supervisions with counselors over this past week and documented. Clinical supervisor will monitor for completeness and program director will monitor this in clinical supervisions with the clinical supervisor. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of patient records, it was discovered that on 05/31/2016, the facility had learned that Patient #13 (an active patient, at that time) had passed away. The facility subsequently discharged the patient on 06/01/2016. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory 48 hours timeframe.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
In accordance with 715.28 (c) (1-5) Unusual Incidents, MCMC program failed to send appropriate documentation to the Department in the regulatory 48 Hour timeframe. This was an oversight and has not happened in the past and will not happen in the future. Report of Consumer #1546 death has been submitted to the department by the Program Director 0n 8/11/16. Program Director will be monitored by Clinical Supervisor as a backup to ensure this oversight may not happen again and future compliance is maintained. |