INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted from September 19 - 21, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Central Montgomery MH/MR Center, 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(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of employee #1's job description and the project's organizational charts, the project failed to ensure that the staff person appointed to the position of project director would be responsible for the overall management of the project and staff.
The findings include:
The published definition for project director as found in 28 Pa. Code, 701.1 is as follows:
Project director - The administrator of the treatment project who is responsible
for the overall management of the project and staff and who meets the education
and experience requirements in Chapter 704.
Employee # 1 was hired on February 1, 1997 as the Director of Outpatient Services. On September 19, 2012, employee #1's revised job description was reviewed along with the project's organizational charts. The revised job description was signed on November 1, 2011.
The job description for employee # 1 contained the following information:
POSITION:
"Director - Outpatient Services / Project Director CORE."
DESCRIPTION OF DUTIES:
"As Director of Outpatient Treatment Evaluation Services....."
-and-
"As Project Director of CORE:
- Assist the governing body in formulating policy, annually update the policy and procedures
and provide a performance report of goals and objectives to the Board of Directors.
- Responsible for the overall management of the CORE program."
HOW SUPERVISION IS PROVIDED:
- Weekly and PRN meetings with Executive Director."
The job description for the Project Director specified that employee #1 is responsible for the overall management of the CORE program. However, the job description did not specify that employee # 1 was responsible for the overall management of the project and staff. Furthermore, the job description did not indicate that employee # 1 was responsible for executing contracts, establishing wage scales, approving personnel policies, managing the project's fiscal matters and that employee # 1 reported directly to the Board of Directors. Therefore, employee #1 is not responsible for the overall management of the project..
A review of Organizational Charts for the project's two facilities revealed that the Outpatient Service Director for the CORE program, employee # 1, reported directly to the Executive Director, who in turn reported to the Board of Directors. The Organizational Chart for the project revealed that employee # 1 reported to both the Board of Directors and the Executive Director. Employee # 1 reported to the Board of Directors as the Project Director and reported to the Executive Director as the Director of Outpatient Evaluation / Treatment Services. The Chart also showed that the Executive Director answered directly to the Board of Directors.
As listed on the Organizational Chart, the Executive Director should be the Project Director.
This is a repeat citation from September 27, 2011.
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Plan of Correction
The Executive Director will be the Project Director for the CORE Program. The Executive Director meets the current education and experience requirements in Chapter 704. The Executive Director's current job description will be revised to reflect this position. It will include the responsibilities of executing contracts, establishing wage scales, managing fiscal matters, and perform other related duties for the CORE Program. This will be completed by 12/14/12. The organizational chart will also be revised to reflect this change. This will be completed by 12/14/12.
Should the agency require hiring a new Project Director, then the Facility Director will work with the Administrative Coordinator to ensure that the potential hire meets the qualifications for the Project Director position.
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705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based upon the physical plant inspection the facility failed to maintain a minimum of two exits on every floor, including the basement.
The findings include:
The physical plant inspection was conducted on September 21, 2012, from approximately 9:45 to 10:35 AM.
The basement, which is used by the Maintenance Department as a workshop, did not contain a 2nd exit.
The findings were confirmed by the Facility Director.
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Plan of Correction
The Facility Director sent request for an exception to this regulation as the building was built in 1900 and due to building structure adding another exit will be financially impossible. The Board of Directors will meet 12/13/12 and will document approval to this exception. The Facility Director will forward this documentation to DDAP on 12/14/12. The basement is used approximately once a month for maintenance and service personnel to repair any plumbing or heating issues as these systems are located in the basement. A sign was posted stating that access to the basement is for authorized personnel only. The basement is kept locked at all times except for when maintenance or service personnel require access.
Should approval for an exception not be granted, the agency will correct the deficiency to meet the requirements of 705.28 (a)(1)(ii). The agency will have contractors assess the building to determine if another exit can be installed and provide an estimate for the cost of such a project. Another exit will be installed by 3/1/13. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based upon the physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail.
The findings include:
The physical plant inspection was conducted on September 21, 2012, from approximately 9:45 AM to 10:35 AM.
The first floor exit to East Basin St. included an outside stairway that contained 6 steps. However, the stairway did not have a handrail in place at the time of inspection.
The basement exit included an outside stairway that contained a minimum of 6 steps. However, the stairway did not have a handrail in place at the time of inspection.
The interior stairway that led to the attic contained a minimum of 9 steps. However, the stairway, including the bottom fold-up section, did not have a handrail in place at the time of inspection.
The findings were confirmed by the Facility Director during the exit interview.
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Plan of Correction
The maintenance personnel will install handrails to the basement, the attic, and out the lobby fire exit by 12/13/12. Maintenance personnel will do a daily check of all handrails to ensure they are properly secured. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
The findings include:
The physical plant inspection was conducted on September 21, 2012, from approximately 9:45 to 10:35 AM.
The Licensing Specialist did not find a smoke detector in the attic.
The findings were not disputed by the Facility Director.
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Plan of Correction
The maintenance personnel placed a battery operated smoke detector in the attic. This will be used until an interconnected system can be determined. The smoke detector in the attic will be added to the fire drill procedure in which smoke detectors are tested monthly. Only maintenance and service personnel have access to the attic. The attic will be kept locked at all times except when service personnel require access. A sign was posted by 11/1/12 that access is for authorized personnel only. An interconnected system will be installed and operational by 3/31/13. Hourly fire watches will be conducted until an interconnected system is installed and operational. |
705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based upon the physical plant inspection and an interview with the Facility Director (FD), the facility failed to maintain a smoke detector in a common area or hallway in the attic. In addition, the facility failed to ensure that all detection devices were interconnected.
The findings include:
The physical plant inspection was conducted on September 21, 2012, from approximately 9:45 to 10:35 AM.
The facility consisted of a basement, an attic, and three other floors.
The Licensing Specialist did not find a smoke detector in the attic. As such, the facility failed to maintain an operable smoke detector in a common area or hallway in the attic.
During an interview with the Licensing Specialist, the FD confirmed that the smoke detectors were battery operated and not hardwired together. Therefore, the smoke detectors were not interconnected.
The findings were not disputed by the FD.
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Plan of Correction
Funding for this project will need to be identified. The Administrative Coordinator has researched different smoke detector systems and will present the information to administrative personnel by January 2013 and determine what will be financially feasible. The attic will be kept locked at all times except when service personnel require access. A sign was posted stating that access is for authorized personnel only. An interconnected system will be installed by March 31, 2013. Until a system can be installed, the agency will continue to utilize the current fire safety practices which include if a smoke detector alarms, the fire marshal on the floor where it alarms investigates the problem, calls the first floor fire marshal to have the fire alarm pulled, and also makes an announcement over the intercom to evacuate the building. In addition to these practices, staff will conduct hourly fire watches. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a portable ABC fire extinguisher on each floor.
The findings include:
The physical plant inspection was conducted on September 21, 2012, from approximately 9:45 to 10:35 AM.
The Licensing Specialist did not locate a fire extinguisher in the attic.
The findings were not disputed by the Facility Director.
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Plan of Correction
The maintenance personnel had the fire extinguisher company install a fire extinguisher by 11/1/12. The attic will be kept locked at all times except when service personnel require access. A sign was posted by 11/1/12 stating access is for authorized personnel only. Maintenance personnel will keep track of all fire extinguishers by using a fire safety log. He will ensure that all fire extinguishers are also kept up to date. This practice will begin 12/17/12. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon a review of the project's Policy & Procedures (P&P) Manual and the project's 2010 / 2011 annual audit, the project failed to have the annual audit completed upon the conclusion of the fiscal year.
The findings include:
The P&P Manual and 2010 / 2011 annual audit were reviewed on September 19, 2012.
As per the P&P Manual, the fiscal year runs from July 1 to June 30.
The annual audit was completed late as it was dated January 31, 2012.
The findings were confirmed by the Project Director during the exit interview.
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Plan of Correction
The Chief Financial Officer will inform the independent public accountant of the timeframe set by the Department in Regulation 709.25. The Chief Financial Officer will monitor the auditing process to ensure the audit will be completed in a timely manner. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based upon a review of employee records and administrative documentation, the facility failed to demonstrate that employees were advised of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
The findings include:
Administrative documentation and three employee records requiring verification of employee rights notification were reviewed on September 19, 2012. The facility was unable to demonstrate that three of three employees, specifically #'s 5, 6, and 7 were advised of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 5 was hired on March 12, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 6 was hired on August 27, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 7 was hired on November 18, 2011. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
The findings were reviewed with the Facility Director following the employee record review.
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Plan of Correction
The Facility Director reviewed employee rights with all current employees including employees # 5, 6, and 7 on 9/20/12 and had them sign a verification form which is kept in the employees' personnel files. The Facility Director will review the employee's rights will all new employees to the Program. This will be completed within the first seven days of employment. Employees will sign off on a verification sheet which will be kept in the employee's personnel files. The Facility Director began this process 9/20/12. |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based upon a review of employee records and administrative documentation, the facility failed to demonstrate that employees were advised of their right to submit rebuttal data or memoranda to his own records.
The findings include:
Administrative documentation and three employee records requiring verification of employee rights notification were reviewed on September 19, 2012. The facility was unable to demonstrate that three of three employees, specifically #'s 5, 6, and 7 were advised of their right to submit rebuttal data or memoranda to his own records.
Employee # 5 was hired on March 12, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 6 was hired on August 27, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 7 was hired on November 18, 2011. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
The findings were reviewed with the Facility Director following the employee record review.
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Plan of Correction
The Facility Director reviewed employee rights with all current employees including employees # 5, 6, and 7 on 9/20/12 and had them sign a verification form which is kept in the employees' personnel files. The Facility Director will review the employee's rights will all new employees to the Program. This will be completed within the first seven days of employment. Employees will sign off on a verification sheet which will be kept in the employee's personnel files. The Facility Director began this process 9/20/12. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based upon the physical plant inspection and an interview with the Facility Director (FD), the facility failed to secure client records within locked storage containers.
The findings include:
The physical plant inspection was conducted on September 21, 2012, from approximately 9:45 to 10:35 AM.
The facility's closed client records were stored in five filing cabinets in a room off the employee kitchenette.
The closed client records were not secured at the time of inspection as five of five file cabinets were not locked. In addition, the chart room door was not locked as it did not contain a lock.
The FD confirmed the findings.
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Plan of Correction
The Facility Director will keep the closed records locked at all times. The Facility Director will maintain the keys for the cabinets and allow access to the records to approved personnel. This procedure has been in place since 9/21/12. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based upon the review of client records, the facility failed to ensure that there was a complete client record to include progress notes that contained the counselor's assessment of the client's progress.
The findings include:
The facility chose to use the Data Assessment Plan [DAP] format for documenting progress notes for individual counseling sessions.
Six client records requiring documentation of progress notes were reviewed from September 20 - 21, 2012. Progress notes contained in three of six records, specifically #'s 1, 5, and 6, did not include the counselor's assessment of the individual's progress or lack thereof.
Client # 1 was admitted on March 12, 2012, and was still an active client at the time of the inspection. The assessment portion of 3 progress notes consisted of standardized comments and failed to assess the client's progress or lack of progress regarding specific goals and objectives contained on the Individual Treatment Plan. The dates of those progress notes are:
May 18, 2012; June 28, 2012; and July 19, 2012
Client # 5 was admitted on February 11, 2011, and was still an active client at the time of the inspection. The assessment portion of 15 progress notes consisted of standardized comments and failed to assess the client's progress or lack of progress regarding specific goals and objectives contained on the Individual Treatment Plan. The dates of those progress notes are:
January 24, 2012; February 28, 2012; March 6, 20, and 27, 2012; April 16 and 27, 2012
May 3, 16, 22, and 30, 2012; June 4 and 19, 2012; July 6 and 18, 2012
Client # 6 was admitted on August 28, 2012, and was still an active client at the time of the inspection. The assessment portion of 3 progress notes consisted of standardized comments and failed to assess the client's progress or lack of progress regarding specific goals and objectives contained on the Individual Treatment Plan. The dates of those progress notes are:
August 28, 2012; September 4 and 18, 2012
The findings were reviewed with the Facility and Project Directors during the exit interview.
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Plan of Correction
The progress notes were reviewed at the monthly CORE meeting on 10/15/12. Currently there is an assessment section in the progress note to document risk assessment, mood/affect, thought process/orientation and behavior/functioning and a section to document client's response to intervention(s)/progress towards goals and objectives in the Data section of the note. The Facility Director reviewed with the therapists what type of information needs to be written in the Assessment Section of the Progress Notes. The Facility Director will continue to review at least two charts per month to ensure proper documentation is occurring.
Clinical staff will include clinical impressions of client progress on all progress notes including clients #1, 5, and 6. |