INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on July 28, 2021 through July 29, 2021 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to follow their own written policy and procedures regarding the completion of the their mechanism to collect completed training feedback for the facility's July 2020 through June 2021 training year in two of six applicable personnel records reviewed.
The facility's policy stated that feedback forms are to be completed by employees following every agency-based training.
Employee #3 was hired on February 10, 2020 and there were no documented feedback forms for any of the agency-based trainings taken during the reviewed training year.
Employee #4 was hired on February 5, 2020 and there were no documented feedback forms for any of the agency-based trainings taken during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be asked to submit all training certificates with an attached training evaluation to their immediate supervisor within 7 days of the training completion. Director will inform staff of this process during 8/13/2021 staff meeting and monitor ongoing compliance as they are filed within personnel charts. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's July 1, 2019 through June 30, 2020 training year.
Employee #1 was hired as the Project Director on February 28, 2018. The personnel record documented 0 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Reginal Director will identify available trainings and communicate with project director. Reginal Director will monitor quarterly for ongoing training compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in the small group room.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director removed the heater from the building. Director will inform staff at 8/13/21 staff meeting that no space heaters are allowed to be brought into the building. Office manager and Program Director will complete a site inspection for any fire hazards during the monthly fire drill and/or fire extinguisher review. |
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 patient records, the facility failed to keep release forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) in two of seven patient records reviewed.
Patient #1 was admitted on April 1, 2021 and was still active at the time of the inspection. The consent to release information form to a government agency, signed by client on April 1, 2021, allowed for the release of the lab and UDS results, chest x-ray results, and medical history, all of which exceeded 4 PA code 255.5.
Patient #3 was admitted on March 24, 2021 and was still active at the time of the inspection. The consent to release information form to a government agency, signed by client on July 28, 2021, allowed for the release of the lab and UDS results, chest x-ray results, and medical history, all of which exceeded 4 PA code 255.5.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Release for the release form in question was updated by the Program Director to specify purpose and medical history as it relates to the referral and requested testing. New release form was shared with program staff 7/30/21. Counselors will do periodic review of client charts for compliance for releases of information. Clinical supervisors then review chart audits in monthly supervisions. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on an administrative review of the facility's unusual incident log, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving an event at the facility requiring the presence of police at the facility on June 25, 2021.
This is a repeat citation from the March 5, 2021 onsite licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Reportable incidents will be reviewed with staff 8/13/2021. Staff will be reminded that all incident reports must be completed within 24 hours and reported to immediate supervisor/program Director immediately following incident. Director will clarify that all 911 responses to the program will be reported as incidents regardless of who makes the 911 call. Reportable incidents will be forwarded to DDAP within 72 hours of incident by program management. Program Director will monitor for ongoing compliance. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document what materials were sent to a receiving narcotic treatment program for a transferring patient in one of one applicable patient record reviewed.
Patient #6 was admitted on December 16, 2015 and was transferred to another narcotic treatment program on May 3, 2021. There was indication that materials were sent to the receiving narcotic treatment program; however, there was no documentation of exactly what was sent.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program will review procedures 8/13/2021 for patient outgoing transfers including: transfer within 7 day time period with any potential reasons for delay documented, all documentation sent to accepting program must be logged/scanned into the EHR system. Clinical supervisors will monitor for ongoing compliance. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document, in writing, that they notified a transferring narcotic treatment program of the admission and date of initial dose of a patient who transferred in to the program in two of two applicable patient record reviewed.
Patient #1 was transferred and admitted to the narcotic treatment program on April 1, 2021 and was still active at the time of the inspection. There was no documentation in the record of the admission date and initial dose date sent to the transferring narcotic treatment program at the time of the inspection.
Patient #3 was transferred and admitted to the narcotic treatment program on March 24, 2021 and was still active at the time of the inspection. There was no documentation in the record of the admission date and initial dose date sent to the transferring narcotic treatment program at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review intake transfer procedures including admission and dose confirmation with intake coordinator. Intake supervisor, the lead counselor, will monitor for ongoing compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure that an annual evaluation, completed by the patient's counselor and reviewed, dated, and signed by the medical director, was documented on the anniversary date of the patient's admission to the narcotic treatment program in one of five applicable patient records reviewed.
Patient #7 was admitted on June 26, 2014 and was still active as of the date of the inspection. There was no documentation of the annual clinical evaluation for 2020 documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and clinical supervisor will review with staff on 8/13/2021 procedures and time frames for completing necessary annual paperwork. Clinical supervisors will be responsible for ongoing compliance. |
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 an administrative review of the facility's unusual incident log, the facility failed to notify the Department within 48 hours of an incident involving the verbal abuse between a patient and a staff member.
There was an internal incident log of an incident, where the patient was verbally abusive to a staff member, that occurred on April 26, 2021; however, the incident was not reported to the Department until July 8, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Reportable incidents will be re-reviewed with staff 9/3/2021. Staff will be reminded that all incident reports must be completed within 24 hours and reported to immediate supervisor/program Director immediately following incident. Reportable incidents will be forwarded to DDAP within 48 hours of incident by program management. Program Director will monitor for ongoing compliance. |