INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a buprenorphine monitoring inspection conducted on October 2, 2019 through October 4, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Mon Yough Community 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:
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Plan of Correction
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, it was determined that the facility failed to complete annual written individual staff performance evaluations on three out of the eight employees that were reviewed.
Employee #2 was hired on April 16, 2018 and was a current employee at the time of the inspection. The last annual written individual staff performance evaluation completed on this employee was on May 24, 2018. The next annual written individual staff performance evaluation would have been due by May 24, 2019. There was no current annual written individual staff performance evaluation documented for this employee as of the date of the inspection.
Employee #5 was hired on May 29, 2018 and was a current employee at the time of the inspection. An annual written individual staff performance evaluation was due by May 29, 2019. There was no current annual written individual staff performance evaluation documented for this employee as of the date of the inspection.
Employee #7 was hired on January 29, 2018 and as a current employee at the time of the inspection. An annual written individual staff performance evaluation was due by January 29, 2019. There was no current annual written individual staff performance evaluation documented for this employee as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire, all staff will have a 90 day review completed by the supervisor. In addition, an annual review is conducted every May, starting in 2020, by the supervisor. Supervisors of staff will work with HR to complete a performance evaluation by 11/30/19 for all staff out of compliance. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of 18 client records, the project failed to notify all 18 clients that they shall retain civil rights and liberties as provided by statute and that no client would be deprived of civil rights solely by reason of treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 10/4/19, Program Director created a Client Rights and Responsibilities document which includes signatures for the client and witness. The document also states if a copy was offered to the client and if the client accepted or refused a copy of the Client Rights and Responsibilities. On 10/04/19, the administrative assistant added the Clients Rights and Responsibilities document was to all intake paperwork and all staff were notified via email of this additional intake document. As of 11/1/19, the Clients Rights and Responsibilities document will be added to the monthly chart audit tool checklist, which is completed by the supervisor and submitted to the Compliance Department on a monthly basis |
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 the review of 18 client records, it was determined that the facility failed to notify all 18 clients reviewed of their right to inspect their own records, 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 and that the reason for removing sections would be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/4/19, Program Director created a Client Rights and Responsibilities document which includes that the individual has the right to inspect his/her own records, MYCS may temporarily remove portions of the records prior to inspection, and the reasons for removing sections of the record is documented within the client's records. The document also contains signatures for the client and witness. In addition, it states if a copy was offered to the client and if the client accepted or refused a copy of the Client Rights and Responsibilities. On 10/04/19, the administrative assistant added the Clients Rights and Responsibilities document to all intake paperwork and all staff were notified via email of this additional intake document. As of 11/1/19, the Clients Rights and Responsibilities document will be added to the monthly chart audit tool checklist, which is completed by the supervisor and submitted to Compliance Department on a monthly basis. |
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 the review of 18 client records, it was determined that the facility failed to notify all 18 clients reviewed of their right to appeal the decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/4/19, Program Director created a Client Rights and Responsibilities document which includes that the individual has the right to appeal a decision limiting access to his/her records. The document also contains signatures for the client and witness. In addition, it states if a copy was offered to the client and if the client accepted or refused a copy of the Client Rights and Responsibilities. On 10/04/19, the administrative assistant added the Clients Rights and Responsibilities document to all intake paperwork and all staff were notified via email of this additional intake document. As of 11/15/19, the Clients Rights and Responsibilities document will be added to the monthly chart audit tool checklist, which is completed by the supervisor and submitted to Compliance Department on a monthly basis. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of 18 client records, it was determined that the facility failed to notify all 18 clients reviewed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/4/19, Program Director created a Client Rights and Responsibilities document which includes that the individual has the right to request the correction of inaccurate, irrelevant, and outdated or incomplete information in their records. The document also contains signatures for the client and witness. In addition, it states if a copy was offered to the client and if the client accepted or refused a copy of the Client Rights and Responsibilities. On 10/04/19, the administrative assistant added the Clients Rights and Responsibilities document to all intake paperwork and all staff were notified via email of this additional intake document. As of 11/1/19, the Clients Rights and Responsibilities document will be added to the monthly chart audit tool checklist, which is completed by the supervisor and submitted to Compliance Department on a monthly basis. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of 18 client records, it was determined that the facility failed to notify all 18 clients reviewed of their right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/4/19, Program Director created a Client Rights and Responsibilities document which includes that the individual has the right to submit rebuttal data or memoranda to their own records. The document also contains signatures for the client and witness. In addition, it states if a copy was offered to the client and if the client accepted or refused a copy of the Client Rights and Responsibilities. On 10/04/19, the administrative assistant added the Clients Rights and Responsibilities document to all intake paperwork and all staff were notified via email of this additional intake document. As of 11/1/19, the Clients Rights and Responsibilities document will be added to the monthly chart audit tool checklist, which is completed by the supervisor and submitted to Compliance Department on a monthly basis.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the project ' s unusual incidents log, it was determined that the project failed to notify the Department within 3 business days following an unusual incident involving the death of a client.
On September 20, 2019, the project was notified that an active client was deceased. This unusual incident was not reported to the Department.
On May 30, 2019, the project was notified that an active client was deceased. This unusual incident was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/3/19, the Program Director completed the written unusual incident documents and submitted the unusual incidents via email to: RA-DAAPI_DIVISION@PA.GOV at 8:55 AM. Director of Compliance updated all Unusual Incident Reporting guidelines, including the Department of Drug and Alcohol Programming forms to be used in incidents involving death or serious injury due to trauma, suicide, medication error or unusual circumstances. On 10/9/19, Program Director sent email to all program staff regarding the necessity to use the DDAP unusual incident documents and submit unusual incidents to DDAP within 3 business days via email, as well as follow internal processes. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the project ' s unusual incidents log, it was determined that the project failed to notify the Department within 3 business days following an unusual incident involving events at the facility requiring the presence of police, fire or ambulance personnel.
On September 23, 2019, an event at the facility required the presence of police, fire or ambulance personnel. This unusual incident was not reported to the Department.
On June 7, 2019, an event at the facility required the presence of police, fire or ambulance personnel. This unusual incident was not reported to the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 10/3/19, the Program Director completed the written unusual incident documents and submitted the unusual incidents via email to: RA-DAAPI_DIVISION@PA.GOV at 8:55 AM. Director of Compliance updated all Unusual Incident Reporting guidelines, including the Department of Drug and Alcohol Programming forms to be used in incidents involving an event at the facility requiring the presence of police, fire, or ambulance personnel. On 10/9/19, Program Director sent email to all program staff regarding the necessity to use the DDAP unusual incident documents and submit unusual incidents to DDAP within 3 business days via email, as well as follow internal processes. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
During an annual onsite licensing inspection on October 3-4, 2019, it was found that the program failed to develop and implement policies and procedures regarding involuntary terminations that includes that involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
By 11/15/19, Program Director will develop and implement policies and procedures that reqarding involuntary terminations, which will be initiated only when all other efforts have failed to retain the client. The policies and procedures will be reviewed by the Director of Compliance by 11/20/19. All program staff will be trained on the policies and procedures by the supervisor by 11/30/19. Documentation of the training and signature of staff in attendance will be kept on the premises. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
During an annual onsite licensing inspection on October 3-4, 2019, it was found that the program failed to develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
By 11/15/19, Program Director will develop and implement policies and procedures to respond to the following unusual incidents: (1) physical assault by a patient. (2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program. (3) Selling of drugs on the premises. (4) Complaints of patient abuse (physical, verbal, sexual and emotional). (5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances. (6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence. (7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern. (8) Theft, burglary, break-in or similar incident at the facility. (9) Drug related hospitalization of a patient. (10) Other unusual incidents the narcotic treatment program believes should be documented.
The policies and procedures will be reviewed by the Director of Compliance by 11/20/19. All program staff will be trained on the policies and procedures by the supervisor by 11/30/19. Documentation of the training and signature of staff in attendance will be kept on the premises
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