INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 2023, 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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704.5(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
Based on a review of four personnel records, the facility failed to ensure one person met the qualifications for the position of project director.Employee #1 was hired as the Project Director on August 15, 2022 and was current in that position at the time of the inspection. Employee #1 had a qualifying master ' s degree, however, did not have 2 years of experience in a human service agency that included program planning experience. These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
As the Facility Director meets the requirements for the Project Director, he will assume that role as well until the Medical Director obtains the 2 years of experience in our agency that includes program planning experience. The Human Resources Specialist will monitor this during the interview and hiring process for potential applicants or internal transfers into this role, should the position become vacant.
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(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 clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of four personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.Employee #3 was promoted to the position of clinical supervisor on February 6, 2023 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying master ' s degree but did not have the required two years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Medical Director will assume the role of clinical supervisor until the current clinical supervisor obtains the remaining three weeks of experience (5/24/23). The Human Resources Specialist will monitor this during the interview and hiring process for potential applicants or internal transfers into this role, should the position become vacant. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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:
(5) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information within seven days of discharge, per facility policy, in two of four applicable records reviewed. Client #4 was admitted on May 9, 2022 and was discharged on June 2, 2022. The follow-up information was not documented until June 13, 2022.Client #7 was admitted on December 15, 2022 and was discharged on December 23, 2022. The follow-up information was not documented until January 11, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Follow-Up Call Policy was reviewed, revised and distributed to the staff responsible for making the follow-up calls. Administrative Support Services Director re-educated those staff on the importance of adhering to the time frames outlined in the policy. A review of 10 charts per month will be completed by the Administrative Support Services Director to ensure the policy is followed. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed. Client #4 was admitted on May 9, 2022 and was discharged on June 2, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on May 9, 2022, with no client signed consent to release information form signed by the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Acknowledgement and General Consent Form was updated to include consent for staff to determine eligibility and benefit information by DHS and all established data bases. This form is reviewed for completion during the daily chart audits. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to include, within their reporting of unusual incidents policy and procedure, a specific policy that addresses how the facility would respond to the selling of illicit drugs on the premises. This was based on the review of the facility's policy and procedure manual during the licensing process. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A comprehensive Incident Reporting Policy was developed to include all the DDAP components as defined in 709.34, including, but not limited to:
- how MCES would respond to the selling of illicit drugs on the premises
- how MCES would respond to theft, burglary, break-in or similar incident at the facility
- policy and procedures for the implementation of a timely and appropriate corrective action plan
- ongoing monitoring of the corrective action plan
- reporting to DDAP a physical assault by a client within three business days.
- reporting to DDAP the presence of police, fire, or ambulance personnel within three business days
In addition to the Incident Reporting Policy, an Incident Report Follow-Up and Plan of Correction Form has been developed to include the investigation of the incident along with the corrective action plan.
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The facility failed to include, within their reporting of unusual incidents policy and procedure, a specific policy that addresses how the facility would respond to theft, burglary, break-in or similar incident at the facility. This was based on the review of the facility's policy and procedure manual during the licensing process. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A comprehensive Incident Reporting Policy was developed to include all the DDAP components as defined in 709.34, including, but not limited to:
- how MCES would respond to the selling of illicit drugs on the premises
- how MCES would respond to theft, burglary, break-in or similar incident at the facility
- policy and procedures for the implementation of a timely and appropriate corrective action plan
- ongoing monitoring of the corrective action plan
- reporting to DDAP a physical assault by a client within three business days.
- reporting to DDAP the presence of police, fire, or ambulance personnel within three business days
In addition to the Incident Reporting Policy, an Incident Report Follow-Up and Plan of Correction Form has been developed to include the investigation of the incident along with the corrective action plan.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to develop a policy and procedures for the implementation of a timely and appropriate corrective action plan, when indicated. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A comprehensive Incident Reporting Policy was developed to include all the DDAP components as defined in 709.34, including, but not limited to:
- how MCES would respond to the selling of illicit drugs on the premises
- how MCES would respond to theft, burglary, break-in or similar incident at the facility
- policy and procedures for the implementation of a timely and appropriate corrective action plan
- ongoing monitoring of the corrective action plan
- reporting to DDAP a physical assault by a client within three business days.
- reporting to DDAP the presence of police, fire, or ambulance personnel within three business days
In addition to the Incident Reporting Policy, an Incident Report Follow-Up and Plan of Correction Form has been developed to include the investigation of the incident along with the corrective action plan.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to develop a policy and procedure for the ongoing monitoring of the corrective action plan. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A comprehensive Incident Reporting Policy was developed to include all the DDAP components as defined in 709.34, including, but not limited to:
- how MCES would respond to the selling of illicit drugs on the premises
- how MCES would respond to theft, burglary, break-in or similar incident at the facility
- policy and procedures for the implementation of a timely and appropriate corrective action plan
- ongoing monitoring of the corrective action plan
- reporting to DDAP a physical assault by a client within three business days.
- reporting to DDAP the presence of police, fire, or ambulance personnel within three business days
In addition to the Incident Reporting Policy, an Incident Report Follow-Up and Plan of Correction Form has been developed to include the investigation of the incident along with the corrective action plan.
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of seven client records and a discussion with facility staff, the facility failed to ensure that a physical assault by a client was reported to the Department within three business days. Client # 6 was admitted on March 3, 2022 and discharged on March 15, 2022. The client record contained documentation of the client being physically assaultive on March 15, 2022, however, the 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
A comprehensive Incident Reporting Policy was developed to include all the DDAP components as defined in 709.34, including, but not limited to:
- how MCES would respond to the selling of illicit drugs on the premises
- how MCES would respond to theft, burglary, break-in or similar incident at the facility
- policy and procedures for the implementation of a timely and appropriate corrective action plan
- ongoing monitoring of the corrective action plan
- reporting to DDAP a physical assault by a client within three business days.
- reporting to DDAP the presence of police, fire, or ambulance personnel within three business days
In addition to the Incident Reporting Policy, an Incident Report Follow-Up and Plan of Correction Form has been developed to include the investigation of the incident along with the corrective action plan.
The Director of Performance Improvement/ Risk Management will ensure all unusual incidents are submitted. The process will be monitored by the Environment of Care Committee on a monthly basis. |
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 a review of client records and a discussion with facility staff, the facility failed to ensure that events at the facility requiring the presence of police, fire, or ambulance personnel were reported to the Department within three business days. Police personnel were onsite on March 15, 2022, however, the 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
A comprehensive Incident Reporting Policy was developed to include all the DDAP components as defined in 709.34, including, but not limited to:
- how MCES would respond to the selling of illicit drugs on the premises
- how MCES would respond to theft, burglary, break-in or similar incident at the facility
- policy and procedures for the implementation of a timely and appropriate corrective action plan
- ongoing monitoring of the corrective action plan
- reporting to DDAP a physical assault by a client within three business days.
- reporting to DDAP the presence of police, fire, or ambulance personnel within three business days
In addition to the Incident Reporting Policy, an Incident Report Follow-Up and Plan of Correction Form has been developed to include the investigation of the incident along with the corrective action plan.
The Director of Performance Improvement/ Risk Management will ensure all unusual incidents are submitted. The process will be monitored by the Environment of Care Committee on a monthly basis.
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