INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2018 through August 23, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.4(a) LICENSURE Staff Qualifications
704.4. Compliance with staff qualifications.
(a) This chapter applies to project directors, facility directors, clinical supervisors, counselors and counselor assistants hired or promoted on or after March 4, 1996.
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Observations
The facility failed to ensure that the facility director had a qualifying degree at the time of hire. Employee #2 was hired on November 1, 2017 in the position of facility director. Employee #2 only had a high school diploma at the time of hiring.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The position of Facility Director is now being fulfilled by the current Clinical Supervisor. As of 9/18/18, the Clinical Supervisor has added the role of Facility Director to his day to day responsibilities. A signed job description of Facility Director has been placed into the Clinical Supervisor's employee file. All new hires credentialing are now verified by the Facility Director before the employee is hired. 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. |
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 a mechanism to collect feedback on all staff completed trainings in all eight personnel records reviewed.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
A training feedback form was developed by the Clinical Director and will now 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 Clinical Supervisor will review training surveys with employees during their monthly supervision. Each completed training survey will accompany a completed training certificate and filed in the employees file. Employees now have access to their training survey as of 8.24.18 |
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 Employees 1, 2, and 3 had written individual training plans documented in their personnel records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staffing now have an individualized written and signed training plan that has been placed in their employee file. Unsigned training plans were updated and signed on 9/17/2018 and placed into all 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. |
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 unannounced fire drills during the months of September, October, November 2017 and January, February, April , May, June 2018. This was discovered based on the review of the August 2017 through July 2018 fire drill logs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer is conducting unannounced fire drills on a monthly basis. Fire drills were being conducted on a quarterly basis and the new monthly fire drills will be recorded in the safety manual. Unannounced monthly fire drills began on 9/13/18 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. |
709.28 (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 13 of 14 client records reviewed. Client # 1 was admitted into the partial hospitalization program on April 6, 2018 and was discharged April 27, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 2 was admitted into the partial hospitalization program on February 27, 2018 and was discharged April 10, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 3 was admitted into the partial hospitalization program on July 26, 2018 and was discharged August 20, 2018. There was documentation that contact was made with an insurance company; however, there was no consent to release information documented in the record prior to the disclosures. Client # 4 was admitted into the partial hospitalization program on December 27, 2017 and was discharged January 19, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 5 was admitted into the partial hospitalization program on June 13, 2018 and was discharged June 29, 2018. There was documentation that contact was made with an insurance company however, there was no consent to release information documented in the record prior to the disclosures.Client # 6 was admitted into the partial hospitalization program on February 26, 2018 and was discharged April 16, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 7 was admitted into the partial hospitalization program on March 6, 2018 and was discharged March 27, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 8 was admitted into the outpatient level of care on February 15, 2018 and was active at the time of inspection. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 9 was admitted into the outpatient level of care on April 30, 2018 and was active at the time of inspection. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 10 was admitted into the outpatient level of care on March 22, 2018 and was active at the time of inspection. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 11 was admitted into the outpatient level of care on December 19, 2017 and was discharged April 26, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 12 was admitted into the outpatient level of care on January 24, 2018 and was discharged May 31, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 13 was admitted into the outpatient level of care on March 20, 2018 and was discharged May 31, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.Client # 14 was admitted into the outpatient level of care on January 29, 2018 and was discharged April 17, 2018. There was documentation that contact was made with an insurance company and a laboratory; however, there was no consent to release information documented in the record prior to the disclosures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To properly obtain informed and voluntary consent from the client, new releases have been created and implemented to address the releases for clients when communicating with insurance and or other government agencies. These releases are now in accordance with the PA state law 255.5. These new releases have been implemented as of September 15, 2018. All releases are being signed during the intake process with our admissions team. In addition, upon admission all clients will sign a release for the laboratory testing company and as of today this company is Quest Diagnostic. The release for the laboratory will allow urine drug screens to be sent out for processing during clients initial intake and throughout the course of their treatment. Quarterly ,during clinical team meeting, releases will be reviewed and discussed on how and when to utilize each release. |