INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2010 through December 8, 2010 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 January 1, 2011.
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records and interview with the Facility Director, the facility failed to ensure that the counselor assistant met the all the qualifications for counselor in one of four personnel records reviewed.
The findings include:
Eight personnel records were reviewed on December 7, 2010. Four of the eight were counselors; one of the four counselors were promoted from counselor assistant to counselor, employee #7. Employee #7 was hired as a counselor assistant on September 8, 2009 and promoted to counselor after the supervision period on March 2010. After reviewing employee #7's personnel record it was discovered that he did not have the 1 year experience for a counselor with a bachelor degree. Employee #7 was promoted to counselor after his six month supervision was completed, but still had six more months as a counselor assistant before being promoted to a counselor. An interview with the facility director also confirmed this was done.
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Plan of Correction
Program Director will carefully review staffing regulations regarding counselor assistant requirements in regard to promotion to counselor with the future hiring of any new staff to remain in compliance with staffing regulations.To ensure this will not happen again, Program Director will criteria with her supervisor to ensure compliance. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all bathrooms had ventilation by exhaust fan or window.
The finding includes:
The physical plant inspection took place on December 8, 2010 around 9:30 am and an interview was conducted with the facility director on the same day. There are two general use restrooms, one observation restroom which is unisex and one handicapped restroom. During the inspection, at approximately 9:45 am, it was observed that the exhaust fan in one of the restrooms was not working. When the facility director was interviewed, she responded that she had been unaware of the problem but would contact the landlord in an effort to repair the the exhaust fan.
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Plan of Correction
Contractor has been hired by program director to install an exhaust fan in patient bathroom. Program Director will monitor for completeness. To ensure that all exhaust fans are installed and working, quarterly inspections will be conducted MCMC Property Manager and report will be submitted to Program Director for monitoring. Target Date for Completion of Installation: 1/15/2011 |
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 tour on December 7, 2010 at around 9:30 am and visual observation on December 6, 2010 at around 12:30 pm, the facility director's office and storage room next to the facility director's office included heaters that was not permanently mounted or installed.
The findings include:
The director's office included a heater that was not permanently mounted or installed. The director explained that due to the location of the office it it was difficult to regulate the room temperature.
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Plan of Correction
Non mounted space heaters have been removed and contractor has been hired to permanently mount space heaters in Director's office and Counselor's offices. All existing staff as well as any new staff will be advised that space heaters are prohibited and MCMC proerty manager will conduct regular inspections to ensure compliance.Program Director will oversee this monitoring. Target Date for completion of permanent installation is 1/15/2011 |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conduct on different times of the day.
The findings include:
The fire drill record was reviewed on December 8, 2010. There was no documentation of a drill conducted during the evening shift. All other drills were conducted on either the morning or afternoon shifts. The facility's hours of operation is Monday through Friday 7 am to 7 pm and Saturday and Sunday 7:30 am to 11 am. The following months were reviewed January 2010, February 2010, March 2010, April 2010, May 2010, June 2010, July 2010, August 2010, September 2010, October 2010 and November 2010.
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Plan of Correction
A meeting was held on 12/9/10 between the Program Director and the MCMC Fire Marshall to ensure that fire drills will be conducted during all clinic hours and days not just morning and afternoon shifts. Program Director will monitor for compliance. |
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 in ten of fifteen rehabilitation client records.
The finding includes:
Fifteen client records were reviewed on December 7, 2010 through December 8, 2010. Psychosocial evaluations were to be documented in twelve rehabilitation client records, #1, 2, 3, 4, 5, 6, 7, 8, 10 and 11.
Client records #1, 2, 3, 4, 5, 6, 7, 8, 10 and 11 failed to document the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
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Plan of Correction
Clinical meeting will be held by the Clinical Supervisor on 1/6/2011 with the staff to review documentation of psychosocial evaluations to ensure that they are evaluative and that they document client's coping skills, assets/strengths, support systems and negative factors that might inhibit treatment. Clinical Supervisor will monitor future documentation for compliance.Target Date for completion: 1/6/2011. |