INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2019 through August 8, 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, 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to document that Employee #2, whom was hired as the facility director on July 8, 2019, the educational requirements to be a facility director. Based on a review of the employee's file, there was no copy of the employee's degree, transcripts, or written verification of education; therefore, DDAP staff were unable to determine if the employee was qualified educationally for the position.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All new hire credentialing is now verified by the Facility Director before the employee is hired. Copies of all supporting documentation are maintained in each employee's file, and all employee files are audited on a quarterly basis by the Project Director to ensure that each employee's credentials qualify for their position and job description. Employee #2 is no longer employed by facility. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to document feedback forms for completed trainings for Employee #1 for the November 1, 2017 through October 31, 2018 training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training feedback form will be developed by the Facility Director to be completed by staff members following every training that they complete. Employees will have 72 hours to complete and submit the training survey following their training. The training surveys will be reviewed with employees during their monthly supervision. Each completed training survey will accompany a completed training certificate and filed in the employees file. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that employee #2, the facility director, had an individual training plan documented in the employee's personnel/training record for the current training year.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All clinical staffing will have an individualized written and signed training plan that to be placed in their employee file. Training plans will be reviewed at a minimum on a yearly basis and the Clinical Supervisor will review and update individualized training plans for each facility staff member. Employee #2 is no longer employed by the facility. |
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
The facility failed to conduct an unannounced fire drill for eight out of the last twelve months - November 2018, December 2018, January 2019, February 2019, April 2019, May 2019, June 2019, and July 2019. Additionally, during the fire drills conducted in September 2018, October 2018, and March 2019, the facility failed to document, on their log, the exit route used for each drill and that the fire alarm or smoke detector was set off at the time of the drill. These incidences of non-compliance were discovered based on the review of the September 2018 through July 2019 fire drill logs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills prior to July, 2019 were conducted under prior ownership and were being conducted on a quarterly basis.
Under the new ownership, the designated Safety Officer will conduct unannounced fire drills on a monthly basis, utilizing fire alarms and documenting fire escape routes.
The new monthly fire drills will be recorded in the safety manual. Unannounced monthly fire drills began on 8/26/19 and will continue on a monthly basis. The Project Director and Facility Director will inspect the fire drill logs on a quarterly basis to ensure proper implementation of fire drill procedures. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's policies and procedures will be updated, reviewed, and signed by the Project Director by September 30, 2019 and thereafter will be conducted annually. The Project Director will make any necessary updates and sign the facility's policies and procedures on an annual basis to document annual review of the policies and procedures. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to document in the project's written procedures for the management of treatment/rehabilitation services the timeframes of completion and who is to complete the following documentation: client orientation, consent to treat forms, treatment plan updates, case consultation notes, aftercare plans discharge summaries, and progress notes.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/30/2019: The facility's Policies and Procedures include procedures for the management of treatment services including the time frames of completion and who is responsible to complete documentation related to client orientation, consent to treat forms, treatment plan updates, case consultation notes, aftercare plans discharge summaries and progress notes.
The facility's Policies and Procedures following were completed by the Project Director of the facility. Ongoing revisions and edits will be completed by the Project Director annually. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
The facility failed to document in Employee #2's personnel file the written verification of qualifying professional credentials. Employee #2 was hired as the facility director on July 8, 2019.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #2 is not currently employed by the facility. All new hires credentialing are now verified by the Facility Director before the employee is hired, and all supporting documentation maintained in each employee file. On a Quarterly basis the Project Director and Clinical Supervisor will review staff qualifications to ensure that each employee's credentials qualify for their position. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to provide documentation of the security and release of electronic records policy and procedure, based on a review of the facility's policy manual on August 7, 2019. The facility's policy and procedure addresses the security and release of paper records; however, the facility currently utilizes an electronic record software program.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility currently uses electronic record software with high levels of security and confidentiality. As of 8/30/2019 the facility's policies and procedures reflect the use of this software and the procedures related to its use. The Project Director is responsible to review and sign this policy and will review, modify if necessary, and sign annually. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of six client records reviewed.Patient #5 was admitted on August 28, 2018 and was discharged on December 26, 2018. There was documentation that the facility billed the funding source for services provided; however, there was no consent to release information documented in the record prior to the disclosures.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients will be required to sign a voluntary consent to release information to their funding source prior to admission to the facility. Project Director will review and sign off on all new admissions to ensure all appropriate and necessary consents to release information are signed by clients prior to admission to facility. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to document the specific information to be released on a consent form in three of six client records reviewed. Client #3 was admitted on January 4, 2019 and was discharged on April 1, 2019. There were two release of information forms, one to the urinalysis lab and one to a local pharmacy, both signed and dated on January 4, 2019, that were missing the specific information to be released.Client #4 was admitted on October 8, 2018 and was discharged on December 12, 2018. There were two release of information forms, one to the urinalysis lab and one to a local pharmacy, both signed and dated on October 10, 2018, that were missing the specific information to be released.Client #5 was admitted on August 28, 2018 and was discharged on December 26, 2018. There was a release of information form to the urinalysis lab, signed and dated on August 28, 2018, that was missing the specific information to be released.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All releases of information will include specific information to be released, will be signed and dated by the client and a witness.
Clinical staff will be trained by the Project Director on the appropriateness of all release forms, including reasons for and limitations of the releases, and will be reviewed for accuracy and completeness by the program coordinator for approval. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document a witness signature on every consent to release information form in six of six client records reviewed.Client #1 was admitted on October 25, 2018 and was discharged on January 29, 2019.Client #2 was admitted on September 21, 2018 and was discharged on December 27, 2018.Client #3 was admitted on January 4, 2019 and was discharged on April 1, 2019.Client #4 was admitted on October 8, 2018 and was discharged on December 12, 2018. Client #5 was admitted on August 28, 2018 and was discharged on December 26, 2018.Client #6 was admitted on December 12, 2018 and was discharged on January 28, 2019.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All necessary release forms will be reviewed for accuracy and completeness by the program coordinator for approval. The coordinator will reinforce this requirement with staff on a quarterly basis to ensure that consent forms have client signature, witness signature and dates of both signatures. |
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
The facility failed to include documentation, in their client rights policy and procedures, that the clients have the right to inspect their records, that portions can be removed by the director prior to the client inspecting, and that the reasons for removal of sections must be documented in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/30/2019 The facility's client rights policies and procedures have been updated to reflect that the clients have the right to inspect their records, that portions can be removed by the director prior to the client inspecting, and that the reasons for removal of sections must be documented in the client's record. The Project Director is responsible for implementing the corrective plan. |
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
The facility failed to include documentation, in their client rights policy and procedures, that the clients have the right to appeal, to the director, any decision limiting access to their records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/30/2019 The facility's client rights policies and procedures have been updated to reflect that the clients have the right to appeal, to the director, any decision limiting access to their records. The Project Director is responsible for implementing the corrective plan. |
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
The facility failed to include documentation, in their client rights policy and procedures, that the clients have the right to request corrections of any 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
As of 8/30/2019 The facility's client rights policies and procedures have been updated to reflect that the clients have the right to request corrections of any inaccurate, irrelevant, outdated, or incomplete information in their records. The Project Director is responsible for implementing the corrective plan. |
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
The facility failed to include documentation, in their client rights policy and procedures, that the clients have the right to provide rebuttal data or memo to their records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/30/2019 The facility's client rights policies and procedures have been updated to reflect that the clients have the right to to provide rebuttal data or memo to their records. The Project Director is responsible for implementing the corrective plan. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one of one applicable records reviewed.Client #4 was admitted on October 8, 2018 and was administratively discharged on December 12, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All client charts will include a cover page that outlines all required clinical documentation (including notice of termination), date each document is completed, and section for the Primary Therapist to initial to indicate completion. The Project Director will review client charts on at least a quarterly basis to ensure compliance.
Clients who are involuntarily terminated from the facility will receive a notice of termination, including reason for such termination with recommended aftercare plan, and also include that the client was given the opportunity to request reconsideration of the facility's decision to involuntarily terminate the client. A copy of the notice will be included in the client's chart.
The Project Director will train staff in New Hire Orientation on the requirement for termination letters to be sent to clients who are involuntarily terminated. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
The facility failed to provide the client an opportunity to request the reconsideration of the facility's decision to involuntarily terminate the client in one of one applicable records reviewed.Client #4 was admitted on October 8, 2018 and was administratively discharged on December 12, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has updated the notification of termination form to include the client's signature, acknowledging that they were given the option to request reconsideration by the facility. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
The facility failed to provide follow up information in the client's complete record in six of six client records reviewed.Client #1 was admitted on October 25, 2018 and was discharged on January 29, 2019.Client #2 was admitted on September 21, 2018 and was discharged on December 27, 2018.Client #3 was admitted on January 4, 2019 and was discharged on April 1, 2019.Client #4 was admitted on October 8, 2018 and was discharged on December 12, 2018.Client #5 was admitted on August 28, 2018 and was discharged on December 6, 2018.Client #6 was admitted on December 12, 2018 and was discharged on January 28, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All client charts will include a cover page that outlines all required clinical documentation (including a follow up call was completed), date each document is completed, and section for the Primary Therapist to initial to indicate completion. The Project Director will review client charts on at least a quarterly basis to ensure compliance.
The Project Director will train staff in New Hire Orientation on the requirement for follow up calls. |