INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency Service, Inc. 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that the clinical supervisor completed a core curriculum in clinical supervision within six months of hire in the position. Employee #3 was hired as the clinical supervisor on May 3, 2021 and has remained in that position. There was no documentation the clinical supervisor had completed a core curriculum in clinical supervision.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor (Employee #3) identified during the survey completed the core curriculum training on February 22, 2022. The job description has been updated to include the need for any individual hired for that position must complete the core curriculum training if they do not have two years of supervision experience.
Human Resources Director will include the core curriculum training in the orientation process for any individual hired who does not have two years of supervision experience. The training will need to be completed within the first 90 days of employment. Completion of the training will be monitored by the Medical Director. |
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 five personnel records, the facility failed to provide documentation showing that clinical supervisors had monthly meetings with their supervisors for the first six months of employment in that position, in one record reviewed. Employee #3 was hired as the clinical supervisor on May 3, 2021 and has remained in that position.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor (Employee #3) received informal supervisions with the CMO that were not documented. The job description has been updated to include the need to have direct supervision for the first six months after hire. Supervisions will continue annually as per the hospital policy.
The supervisions will occur monthly by the Medical Director and will be formally documented. The supervision documentation will be submitted to Human Resources to be included in the employees personnel file. Human Resources will monitor completion of monthly documentation and apprise the Medical Director of compliance. The medical director will be responsible to ensure compliance with supervision requirements.
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705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection on February 15, 2022, the facility failed to ensure that each toilet had toilet paper at all times, as the single stall bathroom on the Men ' s Unit had no toilet paper. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Facilities will complete a daily walkthrough of all bathrooms to ensure toilet paper is provided at each toilet at all times. The Director of Facilities sent an educational memo to all cleaning staff to inform them that they are to ensure the bathrooms are stocked with toilet paper at all times.
During the physical plant walkthrough with the surveyor on February 15, 2022, a male patient had just exited the bathroom prior to us walking in, which was why the stall had no toilet paper. The issue was immediately corrected while the surveyor was in the building. All bathrooms have been checked daily and the Director of Facilities will continue a daily walkthrough of each bathroom to ensure toilet paper is provided at each toilet at all times.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. The documentation was missing all seven records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient/Family Handbook, which is provided to each patient on admission, and Confidentiality Policy have been updated regarding the clients right to inspect their records and includes:
The CEO or CMO may temporarily remove portions of the records prior to inspect by the client if the CEO or CMO determines that the information be detrimental to the client.
The reason for removing the sections are to be documented in the client's record.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including that clients have the right to appeal a decision limiting access to their records to the director, in all records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient/Family Handbook, which is given to each patient on admission, and Confidentiality Policy have been updated to included that the client has a right to appeal a decision limiting access to their records to the CEO.
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