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 6, 2010 through January 7, 2010 licensure renewal inspection. The follow-up inspection was conducted on August 10, 2010 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 and a plan of correction is due on September 10, 2010.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction
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Plan of Correction
MCMC Program Director has contacted Corporate Fiscal Officials to advise and ensure that the fiscal audit must be completed no later than 6 months after the close of the books which is no later than 12/30 in the fiscal year. RHD HUB Management will monitor corporate officials for compliance. Time Frame: Completed |
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 psychosocial evaluations that included all required information in eight of eight active records reviewed.
The finding includes:
Sixteen records were reviewed on August 10, 2010. Psychosocial evaluations were required in eight active client records reviewed.
Client record #1, 2, 7, 8 failed to provide documentation the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client record #3, 4, 5 failed to provide documentation the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #6 failed to document psychosocial evaluation in record reviewed. Client was admitted on 5/6/10 and as of to date an evaluation was not documented.
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Plan of Correction
A Clinical Meeting was held by the Clinical Supervisor with MCMC staff on 8/13/10 to review psychosocial process completion to provide assets/strengths/support systems, coping mechanisms and negative factors that might inhibit treatment as well as to include the counselor sonclusions and impressions. Clinical Supervisor will review these upon each completion and the program director will supervise the Clinical Supervisor regarding this compliance. |