INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Montco Recovery Center LLC 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's August 2023 through May 2024 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.There were no fire drills during the months of January 2024 and February 2024 documented in the facility's fire drill logs.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
With the arrival of new clinical management in March of 2024, the monthly Fire Drills have been reinstituted (with the first one conducted on 3/20/24) for unannounced implementation moving forward. The responsible staff have been reeducated on the importance of conducting such. Facility Safety Officer has been appointed and entrusted with the duty of conducting Fire Drills on a monthly basis. Fire Drills Log is being audited monthly by the Clinical Director, at whose discretion an unannounced drill can be called into action if such has not been conducted by the Facility Safety Officer in a timely manner, or in case the latter is away or otherwise unavailable. The Clinical Director will be ultimately responsible for auditing and maintaining consistency with carrying out unannounced monthly fire drills. |
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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.Client # 7 was admitted to the partial hospitalization activity on September 22, 2023 and was discharged on October 25, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With the arrival of new Clinical Management in March of 2024, comprehensive monthly chart audits have been created and from there on out consistently carried out for purposes of assuring that no piece of necessary documentation is overlooked. The mentioned monthly audits include, among other items, review of financial and legal informed consents and voluntary releases of information. The audits are being conducted by the Clinical Director at MRC. Staff, to whom completion of such pertains, has received re-education both prior to this finding, and upon being informed of such, on the importance of making sure that all the documentation pertinent to client's intake, billing, continuous stay in treatment, and appropriate discharge is completed in an accurate and timely manner. A comprehensive Employee Orientation packet has been written by the Clinical Director, in part of which, all the documentation pertinent to informed consents and voluntary releases of information (both financial and otherwise) is comprehensively outlined. Staff has received an education session on utilization of the new Employee Orientation packet during one of the multidisciplinary treatment team meetings, at which point hard copies of the packet have been distributed. Additional questions regarding utilization/interpretation of such have been addressed during individual supervision sessions. Staff taking part in this reeducation included all individuals under whose responsibility a completion of mentioned consents and releases of information may fall. Clinical Director will be ultimately responsible for making sure that informed and voluntary consents and releases of information are being appropriately completed and signed by all clients to whom they pertain. As evidenced by findings of the mentioned monthly audits conducted from March of 2024 and to this date so far, the facility appears to be in full compliance with regards to completion of mentioned informed consents and pertinent releases of information. |