INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 7, 2018 through August 8, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that each employee had a written individual training plan, as this was discovered during the review of personnel files. Employees #8, 13, 14, 15, 16, and 17 did not have a training plan documented in their respective files.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
MCRC has put a procedure in place for the New Hire Coordinator to check off a list of the necessary items to be included with every new hire packet to include the completion of training plans for all employees. The paperwork will then be reviewed by the program director for completion and compliance.
This has been implement effective 8/17/18. |
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
The facility failed to instruct all staff in the use of the fire extinguisher upon staff employment as employee #8, who has been employed since June 18, 2018, had not received this training as of the date of the inspection.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
MCRC has put a procedure in place for the New Hire Coordinator to check off a list of the necessary items to be included with every new hire packet to include the instruction of all new staff regarding the use of the fire extinguishers and the sign off that this instruction was given. The paperwork will then be reviewed by the program director for completion and compliance.
This has been implement effective 8/17/18. |
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.
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Observations
The facility failed to ensure all staff were trained in emergency procedures upon staff employment as employee #8, who has been employed since June 18, 2018, had not received this training as of the date of the inspection.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
MCRC has put a procedure in place for the New Hire Coordinator to check off a list of the necessary items to be included with every new hire packet to include the instruction of all new staff regarding all emergency procedures and the sign off that this instruction was given. The paperwork will then be reviewed by the program director for completion and compliance.
This has been implement effective 8/17/18. |
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
The facility failed to report seven unusual incidents that should have been reported to the Department for the September 2017 through July 2018 timeframe reviewed. On October 12, 2017 and November 15, 2017, incidents occurred that required police presence at the facility. On October 9, 2017, May 1, 2018, June 23, 2018, and twice on August 23, 2017, incidents occurred that required ambulance/EMT presence at the facility.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
MCMC Program Director has put in place pre made fax sheets to have ready in the incident log for any unusual incidences that require EMT/police/ambulance contact at MCRC. These shall be sent to DDAP and confirmation will be kept in the incidence log for future reference. This is effective immediately. Program Director and Assistant Director will ensure this 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
The facility failed to provide documentation that they notified client #2's prior narcotic treatment program that the facility had admitted the client, as well as the date of the initial dose given to the client.
Client #2 was admitted on June 23, 2018 and was still active at the time of the inspection.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
An inservice has been held with the intake staff by the program Director and Clinical Supervisor to review protocol for transfer of patients to this facility and paperwork that needs to be submitted to the transferring facility regarding dose confirmation.
Date of Completion: 8/17/18 |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in five of fourteen client records reviewed.
Client #4 was admitted on May 23, 2017 and discharged on February 6, 2018. The last treatment plan update was completed on October 6, 2017. An update should have been completed no later than December 6, 2017; however, the update was not completed prior to discharge.
Client #6 was admitted on August 15, 2017 and discharged on March 29, 2018. The last treatment plan update was completed on December 5, 2017. An update should have been completed no later than February 5, 2017; however, the update was not completed prior to discharge.
Client #8 was admitted on February 12, 2018 and was still active at the time of the inspection. The last treatment plan was completed on March 13, 2018. An update should have been completed no later than May 13, 2018; however, the update was not completed as of the date of the inspection.
Client #11 was admitted on December 28, 2017 and was still active at the time of the inspection. The last treatment plan was completed on May 23, 2018. An update should have been completed no later than July 23, 2018; however, the update was not completed as of the date of the inspection.
Client #14 was admitted on September 29, 2016 and was discharged on June 27, 2018. The last treatment plan update was completed on July 11, 2018 and the next update was due no later than September 11, 2017; however, the update was not completed until September 22, 2018.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
A clinical meeting has been scheduled by the clinical supervisor and MCRC clinical staff to review treatment planning and to insure that treatment plan updates are done within the regulatory timeframes for compliance. Clinical Supervisor will monitor this compliance in individual supervisions and Program Director will oversee this project.
Date of Completion: 9/7/2018 |