INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2007 through August 16, 2007 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on September 14, 2007.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of administrative and personnel documentation it was determined that the facility failed to document monthly meetings between the supervisor and the subordinate clinical supervisor in the first 6 months of employment. Documentation was missing for 2/07, 3/07 and 4/07.
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Plan of Correction
From May 2007 and through the six months and as needed thereafter, the Director will conduct and document monthly supervision meetings with the Clinical Supervisor. |
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 administrative documentation it was determined that the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in four of nine client records reviewed, #2, 4, 6 and 8. The training for employee #5 was not completed until more than 7 days from the date of employment.
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Plan of Correction
New procedures will be implemented to ensure the new staff shall be instructed regarding the use of the fire extinguishers. This will be the responsibility of the appointed fire marshall and will be documented and included in respective personnel charts.
Time Frame: 11/14/07 |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of administrative documentation it was determined that the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. Supporting documentation was missing from four of nine employee records reviewed, #2, 4, 6 and 8. Documentation for employee #5 demonstrated that the training was not completed until more than 7 days from the date of hire.
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Plan of Correction
New procedures will be implemented to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. This will be done upon new hire date and by the fire marshall and supportive documentation will be included in personnel charts.
Time Frame: 11/14/07 |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation it was determined that the facility failed to provide the annual report within 6 months of the fiscal year ending June 30, 2006. The annual report was made available to the public on June 25, 2007.
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Plan of Correction
MCMC will generate it's own fiscal report independent from parent company to ensure that the report will be available for fiscal year ending June 30, 2008 |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of administrative documentation it was determined that the facility failed to document in four of nine records the employees' 90 day performance evaluation as described in facility policy and procedure. Ninety day performance evaluations were missing from client records #2, 6, 7 and 9. The 90 day performance evaluation for employee #5's was not documented until more than 90 days from the date of employment.
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Plan of Correction
The facility will revise the policy to reflect performance evaluations conducted every 12 months.
Time Frame for Revision: 11/14/07 |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a review of administrative documentation it was determined that the facility failed to inform the employees of their 90 day evaluation in four of nine personnel records reviewed, #2, 6, 7 and 9.
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Plan of Correction
Policy will be revised to eliminate the need for a 90 day Performance Evaluation by Program Director.
Time Frame: 11/14/07
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of administrative documents and client records it was determined that the facility failed to inform clients that they can verbally revoke a consent to release information form. This was evident in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 8, 9, 10 and 11. The "Medical Emergency Release" form states "...may withdraw release by submitting a written order".
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Plan of Correction
The Medical Emergency Release form has been revised to include the verbage " may withdraw form verbally or in writing.
Time Frame: Completed |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records it was determined that the facility failed to document the clients' progression of use, a part of the clients' patterns of use, in drug and alcohol histories in nine of nine records reviewed, #1, 2, 3, 4, 5, 6, 8, 9 and 10. There was conflicting information regarding a client's usage in client record #1.
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Plan of Correction
Direct Supervision of Intake Coordinator will be held to instruct on the proper completion of documentation regarding drug use and progression of such use on the psychosocial form.
Time Frame: 11/14/07 |
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 it was determined that the facility failed to evaluate the client in the psychosocial evaluation in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 8, 9, 10 and 11. The psychosocial evaluation was historical rather than evaluative.
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Plan of Correction
The Program Director will conduct individual training with the Intake Coordinator regarding the proper completion of the Psychosocial Form to properly relect that the history recorded is evaluative as opposed to historical. The Program Director will also sit in with intakes initially and complete the psychosocial form in front of the Intake Coordinator to model the proper conduction and documentation of the psychosocial form.Program Director will monitor these forms after each intake for the next 3 months to insure proper completion as well as periodically therafter to insure that this does not happen again.
Time Frame: 11/14/07 |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of the clients' records it was determined that the facility failed to individualize the clients' treatment plans pertaining to short and long-term goals in ten of ten records reviewed, 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11.
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Plan of Correction
A PCB approved Treatment Planning Training has been conducted for MCMC staff to instruct the staff regarding the proper documentation of treatment planning regarding short and long term goals. Clinical Supervisor will monitor treatment plans weekly to ensure that this will not happen again and that treatment plans are including the documentation of short and long term goals.
Time Frame: Completed 9/17/07 |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records it was determined that the facility failed to individualize the clients treatment plans pertaining to type and frequency of service in ten of ten client records reviewed, 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11.
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Plan of Correction
A PCB approved Treatment Planning training has been conducted for MCMC staff to instruct regarding the proper written documentation regarding the type and frequency of rehabilitative services.Clinical Supervisor will monitor treatment plans weekly to ensure that this will not happen again and that the type and frequency of rehabilitative services are properly documented.
Time Frame: Training Completed 9/17/07
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records it was determined that the facility failed to individualize the clients' treatment plans pertaining to support services in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 8, 9, 10 and 11.
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Plan of Correction
A PCB approved Treatment Planning training has been conducted for MCMC staff to instruct regarding the proper written documentation regarding proposed type of support services.Clinical Supervisor will monitor treatment plans weekly to ensure that this will not happen again and that proposed types of support services are properly documented.
Time Frame: Training Completed 9/17/07 |
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
Based on a review of client records it was determined that the facility failed to document treatment plan updates that reflected the clients progress or lack of progress on specific treatment goals and objectives in eight of nine records reviewed, #1, 2, 3, 4, 5, 6, 8 and 9.
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Plan of Correction
A PCB approved Treatment Planning training has been conducted for MCMC staff to instruct regarding the proper written documentation regarding updates that reflect client's progress on specific treatment goals and objectives.
Clinical Supervisor will monitor treatment plans weekly to ensure that this will not happen again and that treatment plan updates will reflect client progress on specific treatment goals.
Time Frame: Training Completed 9/17/07 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records it was determined that the facility failed to document counseling services according to the individual treatment and rehabilitation plan in three of nine records reviewed, #4, 8 and 9. There were a lapses in treatment with no supporting documentation and/or justification for the break in treatment listed in the progress notes.
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Plan of Correction
A PCB approved Treatment Planning training has been conducted for MCMC staff to instruct regarding the documentation of counseling services according to individual treatment and rehabilitative palns. Also to instruct regarding documentation of any lapses that may occur in treatment. Clinical Supervisor will monitor treatment plans weekly to ensure that this will not happen again.
Time Frame: Completed 9/17/07 |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records it was determined that the facility failed to document that counseling was provided to all clients on a regular and scheduled basis in three of nine records reviewed, #4, 8 and 9. There were lapses in treatment with no justification or supporting documentation in the progress notes.
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Plan of Correction
A PCB approved Treatment Planning training has been conducted for MCMC staff to instruct regarding the documentation that counseling was provided to all clients on a regular and scheduled basis and that lapses were recorded in the progress notes.Clinical Supervisor will monitor this in regular supervision of counselors weekly to ensure that this will not happen again.
Time Frame: Completed 9/17/07 |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of the client records it was determined that the facility failed to document records of services which included group therapy sessions in nine of nine client records reviewed, #1, 2, 3, 4, 5, 6, 8 and 9.
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Plan of Correction
The Record of Service log will be redesigned to delineate between Individual and Group Services to properly document attendence at these services.
Time Frame: 11/14/07 |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records it was determined that the facility failed to document measurable goals that were consistent with the identified needs and problems of the client in the aftercare plans in four of four client records reviewed, #5, 6, 7 and 10. Aftercare plans were not individualized.
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Plan of Correction
Facility will redesign the MCMC Aftercare Plan to be more consistent with identifying needs and problems of the clients as well as making them more individualized. An inservice training will be held to go over the proper completion of the form and the clinical supervisor and senior clinician will monitor these formsduring chart audits on a quarterly basis.
Time Frame: 11/14/2007 |