INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2011 through February 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency Services 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 and a plan of correction is due on March 4, 2011.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's policy and procedure manual and a discussion with the administrative assistant, the facility failed to ensure that all staff documented their assessment of staff training needs.
The findings include:
The personnel records and policy/procedure manual was reviewed on January 31, 2011 through February 1, 2011. A discussion with the administrative assistant and human resource personnel revealed that the assessment of staff training needs surveys were anonymous and they were unable to identify who filled them out.
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Plan of Correction
Assessment of staff training is done annually and given to all clinical staff for completion. However, minimal response is received. The assessment tool is being revamped by the Education Committee to include staff member's name, so they are no longer anonymous. The annual survey will be mandatory for all staff. The Education Plan will be revised by the Education Committee to clarify the staff training year. The annual staff training survey will be done in May to accommodate both possible plan years. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure and document that project director/facility director completed at least 12 hours of training for the 2010 training year in one of one personnel record.
The findings include:
Six personnel records were reviewed on January 31, 2011 through February 1, 2011. One employee record represented the project director/facility director who was required to have obtained 12 hours of training for the 2010 training year based on the hire dates, #1. A discussion with the administrative assistant and human resource staff confirmed that the required training hours was not obtained for training year 2010.
Employee #1 was hired September 10, 1984 and was required to have obtained 12 hours of training for the 2010 training year. Employee #1 had no training documented for training year 2010
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Plan of Correction
Staff will be educated to provide certificates whenever they attend an outside training. The Human Resources Department will be responsible to obtain certificates for all trainings. Education Committee to review entire DAPL standards regarding staff education to make sure MCES policies are consistent. We are also requesting clarification from DAPL regarding these standards. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure and document that counselors completed at least 25 hours of training for the 2010 training year in five of five personnel record.
The findings include:
Six personnel records were reviewed on January 31, 2011 through February 1, 2011. Five employee records represented the counselors who were required to have obtained 25 hours of training for the 2010 training year based on the hire dates, #2, 3, 4, 5 and 6. A discussion with the administrative assistant and human resource staff confirmed that the required training hours was not obtained for training year 2010.
Employee #2 was hired July 1, 2010 and was required to have obtained 25 hours of training for the 2010 training year. Employee record #2 had no training documented for training year 2010.
Employee #3 was hired June 22, 2009 and was required to have obtained 25 hours of training for the 2010 training year. Employee record #3 only documented 12 hrs of training for training year 2010.
Employee #4 was hired September 8, 2009 and was required to have obtained 25 hours of training for the 2010 training year. Employee record #4 only documented 16 hrs of training for training year 2010.
Employee #5 was hired May 12, 2008 and was required to have obtained 25 hours of training for the 2010 training year. Employee record #5 recorded no training for training year 2010.
Employee #6 was hired September 12, 1986 and was required to have obtained 25 hours of training for the 2010 training year. Employee record #6 documented 9 hrs of training for training year 2010.
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Plan of Correction
Staff will be educated to provide certificates whenever they attend an outside training. The Human Resources Department will be responsible to obtain certificates for all trainings.
Education Committee to review entire DAPL standards regarding staff education to make sure MCES policies are consistent. We are also requesting clarification from DAPL regarding these standards.
Employee #2 just graduated from medical school in June 2010 and his training plan is good until 6/30/11.
Some of the trainings completed by the counselors were on-line trainings through the APA. However, we were notified during the survey that only on-line trainings after 9/1/10 would be counted. We had sent two letters (4/20/10 and 8/11/10) requesting these be approved, but were not informed of the 9/1/10 approval date until the survey. |
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:
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Observations
Based on the review of the client record and a discussion with the Project Director, the facility failed to obtain a consent to release form in one of one record reviewed.
The findings include:
One client record was reviewed on February 1, 2010. Consent to release forms were required in record #1. Record #1 had a document pertaining to the client's benefits that had identifying information regarding the client. There was no documentation of a consent to release form for this agency. A discussion was conducted with the project director pertaining to this issue and she agreed it was not included in client record #1.
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Plan of Correction
The Outpatient Secretary has been reeducated regarding the importance of confidential release forms being in the record for anyone we have contact with. She will be responsible to make sure they are completed. Administrative Assistant, as her supervisor, will review records to ensure release forms are completed. A release form has since been signed by the client and placed in the record.
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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 one of one rehabilitation client records.
The finding includes:
One client records were reviewed on February 1, 2010. Psychosocial evaluations were to be documented in record #1. Per the facility's policy and procedure manual, psychosocial evaluations will be completed by the fourth session after admission. Client record #1 was admitted on December 8, 2010 and the client's fourth session was documented on December 28, 2010. As of the date of the inspection there was no documentation of the client's psychosocial evaluation. A discussion with the project director took place on February 1, 2010 and it was confirmed that the psychosocial evaluation was not documented.
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Plan of Correction
The client was admitted to the Outpatient Program on 12/8/10, and a thorough psychiatric assessment was completed. The fourth session was 12/28/10. On that date the psychosocial evaluation was completed by the client and signed by the therapist. A more thorough psychosocial assessment will be done at the time of the psychiatric evaluation by the therapist. Outpatient Secretary will be responsible to monitor. |
709.92(a) 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:
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Observations
Based on the review of client records and a discussion with the project director, the facility failed to document timely clients comprehensive treatment plan in one of one record reviewed.
The findings include:
One record was reviewed on February 1, 2011. Comprehensive treatment plans were required in one record reviewed. Per the facility's policy and procedure manual comprehensive treatment plans are to be completed by the 4th session after their admission date and completion of the client ' s history and psychosocial evaluations. A discussion with the project director on February 1, 2011 confirmed that it was completed before the history and psychosocial evaluation.
Client record #1 was admitted on December 8, 2010 and their history completed on December 28, 2010 and no documentation of the clients psychosocial evaluation. Their comprehensive treatment plan was completed on December 21, 2010 before the completion of the client ' s personal history and psychosocial evaluation.
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Plan of Correction
The Outpatient Secretary was reeducated regarding the policy of proper documentation and chronological order of documentation. She will be responsible to monitor that the treatment plan is completed after the psychosocial assessment and by the fourth session. Administrative Assistant, as her supervisor, will monitor compliance with the policy. |