INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 3, 2013, to December 5, 2013, 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings included:
Five personnel records were reviewed on December 3, 2013. One personnel record reviewed was that of the clinical supervisor. This personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 2.
Employee # 2 was hired on January 2, 2013, as the clinical supervisor. Monthly supervision meetings were required to take place in January, February, March, April, May and June 2013. There was no documentation of monthly supervision meetings in the personnel record of employee # 2.
The findings were reviewed with the facility director on December 3, 2013 at which time it was confirmed that there was no documentation of monthly supervision meetings.
|
Plan of Correction
Clinical Supervisor and Program Director will meet for supervision for the next six months monthly and there shall be documentation of these meetings. Clinical Supervisor will insure that all counselors are receiving supervision and documentation thereof as per staffing regulations. Program Director will monitor this action. Meeting completed 12/23/2013 |
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.
|
Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of one records reviewed.
The findings included:
The facility's SRFSR form completed by the facility on November 22, 2013, was reviewed on December 3, 2013. The form listed one clinical staff as not having completed the mandatory training within the regulatory time frames.
Employee # 6, a counselor, was hired on September 4, 2012. Employee # 6 was required to obtain 4 hours of TB/STD training by September 4, 2013. The training was not documented until November 14, 2013.
The findings were confirmed by the facility director.
|
Plan of Correction
Clinical Supervisor and Program Director will ensure that all future new employees hired will complete mandatory training for HIV, TB, STD in the first year of hire as per staffing standards. Both Clinical Supervisor and Program Director will monitor this for compliance. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
Based on observation and a physical plant inspection, the facility failed to provide an unobstructed exit to the rear exit.
The findings included:
A physical plant inspection was conducted on December 3, 2013. The door for the rear exit through the storage area was blocked by a door that was propped open with a door stop. Therefore, this exit was not unobstructed and operable at all times.
The facility director confirmed the pattern of propping the door open with a door stop blocking the rear exit from the storage area of the facility.
|
Plan of Correction
Door stop has been discarded and plans have been made with MCMC maintenence man to switch hinges to other side of door jam to prevent future obtructions and to ensure that door is operable at all times. Completion Date 1/7/2013 |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
|
Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in one of five personnel records.
The findings included:
Five personnel records were reviewed on December 3, 2013. The facility failed to obtain the required documentation of a signed job description in personnel record # 3.
Employee # 3 was hired on October 21, 2013, as a counselor. There was no documentation of a signed job description in personnel record # 3 at the time of the review.
The facility director was informed of the findings and confirmed that there was no documentation of a job description in the personnel record.
|
Plan of Correction
Program Director will ensure that all future new employees hired will complete all required paperwork including a signed job description and this paperwork will be part of the employee personnel record. Program Director will be responsible for this compliance. |
709.28(c) 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 shall be in writing and include, but not be limited to:
|
Observations
Based on the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in one of eleven records. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one record reviewed.
The findings included:
Fourteen patient records were reviewed on December 4, 2013, to December 5, 2013. The facility failed to ensure that an informed and voluntary consent to release information was obtained in patient record, # 13. The facility also failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in that record.
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers,
insurance company health or hospital plan or governmental officials, under subsection
(a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability
of continuing the client with the assigned project and shall be restricted to
the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or
alcohol abuse and the frequency of such relapse.
A review of patient record # 13 revealed a progress note documenting information disclosed to a government entity dated November 7, 2013, that identified the disclosure of the results of urine drug screens. This information was beyond that permitted by 4 Pa. Code 255.5 (b). Additionally, the record contained a consent to release information to the patient that failed to identify the information to be disclosed and identified the purpose as dosing history.
The findings were reviewed and confirmed by the facility director.
This is a repeat deficiency from the January 23, 2013, on-site review.
|
Plan of Correction
An inservice will be held by Clinical Supervisor, Program Director and MCMC Clinical staff to review the limits imposed by 4 PA Code 255.5 to insure that an informed and voluntary consent to release information is information only permitted by the scope of this code. CS and PD will monitor for future compliance. Date to be Completed 1/3/2014 |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on the review of patient records, the facility failed to document a detailed history that included medical, drug or alcohol history, and personal history in four of four records reviewed.
The findings included:
Fourteen patient records were reviewed on December 4, 2013, and December 5, 2013. Four records were reviewed for patient histories. The facility failed to document a drug and alcohol history that included lengths and patterns of use in patient records # 2, 8, and 10. Record # 12 did not contain a documented drug and alcohol history at the time of the review. The facility failed to document detailed personal histories in patient records # 2, 8, and 10. Record # 12 did not contain a documented personal history at the time of the review.
Patient record # 2 failed to include a detailed educational history.
Patient record # 8 failed to include a detailed legal, employment and educational history.
Patient record # 10 failed to include a detailed legal, employment and educational history.
|
Plan of Correction
An inservice will be held by the Clinical Supervisor and the Program Director to review the Psychosocial History form to be completed to ensure that all areas of personal history including drug and alcohol history, military history, vocational and educational, legal history be completed in detail to include accurate dates and lengths of time as well as patterns of use. CS will monitor for complaince and PD will oversee this project. Date to be completed: 1/3/14 |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
|
Observations
Based on the review of patient records, the facility failed to document a thorough physical exam in two of ten records reviewed.
The findings included:
Fourteen patient records were reviewed on December 4, 2013, and December 5, 2013. Ten records were reviewed for physical exams. The facility failed to document vital signs, a review of organ systems and general appearance on the physical exam form in records # 3 and 6.
Patient record # 3 contained a physical exam that did not include a review of organ systems and the general appearance of the patient.
Patient record # 6 contained a physical exam that did not include vital signs and the general appearance of the patient.
|
Plan of Correction
A meeting was held on 12/27/13 between the Medical Director and the Program Director and another meeting will be held on 1/3/2014 with the Physician on call to address the need for complete documentation of physical exams to include vital signs, organ system review and general appearance as well as all other catagories required to complete this exam. Program Director will monitor for compliance. Date to be completed: 1/3/2014 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based upon a review of patient records, the facility failed to document a psychosocial evaluation that included an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and the counselor's conclusions/impressions in three of three records.
The findings included:
Fourteen patient records were reviewed on December 4, 2013, and December 5, 2013. Three records were reviewed for psychosocial evaluations.
Patient # 8 was admitted on September 10, 2013. The psychosocial evaluation failed to document an assessment by the counselor that included the patient's problems/needs, assets/strengths, and clinical impressions.
Patient # 10 was admitted on September 18, 2013. The psychosocial evaluation failed to document an assessment by the counselor that included the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and counselor conclusions/impressions.
Patient # 12 was admitted on September 19, 2013. The psychosocial evaluation was not documented in the record at the time of the review.
|
Plan of Correction
An inservice will be held by the Clinical Supervisor and the Program Director to review the Psychosocial History form to be completed to ensure that these evals include appropriate documentation of patient's assets/strengths, support systems, coping mechanisms, negative factors, patient's attitudes toward treatment and the counselor's impressions/conclusions. CS will monitor for compliance and PD will oversee this project. Date to be completed: 1/3/14
|
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.
|
Observations
Based upon a review of patient records, the facility failed to document treatment plan updates which addressed progress achieved during the reporting period on the stated goals of the treatment plan in three of eight records.
The findings included:
Fourteen patient records were reviewed on December 4, 2013, and December 5, 2013. Eight patient records were reviewed for treatment plan updates. Three records failed to document progress on stated goals of the comprehensive treatment plan, # 3, 6, and 7.
Patient record # 3 contained a treatment plan update dated September 30, 2013, with identical progress to the previous treatment plan.
Patient record # 6 contained a treatment plan update dated October 28, 2013, with identical progress to the previous treatment plan.
Patient record # 7 contained a treatment plan update dated October 29, 2013, with identical progress to the previous treatment plan. Additionally, the treatment plan did not have a patient signature at the time of the review.
|
Plan of Correction
An inservice will be held onby the Clinical Supervisor and the Program Director to review the documentaion of treatment plans and the need to document patient progress on stated goals that were identified on the comprehensive treatment plan. CS will monitor for compliance and PD will oversee this project. Date for Completion: 1/3/2014 |