INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 29, 2010 through March 30, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on April 27, 2010.
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure and document that counselors completed at least 25 hours of training for the training year 2009 in one of four personnel records.
Findings:
Five personnel records were reviewed on March 30, 2010. Twenty-five hour training were required in two of four personnel records reviewed.
Employee #2 was hired May 5, 2008 and only had 15 hours of training for the 2009 training year.
|
Plan of Correction
Employee # 2 had on-line CME credits; however, we were not aware that these were not recognized by BDAP. We are submitting a letter to BDAP requesting that these be approved for education hours.
All clinical supervisors were reeducated at the Medical Staff meeting on 4/7/10 regarding the need to complete 25 hours of training per training year. Director of Human Resources and Administrative Assistant will review training mid-year to determine the status of training hours and inform staff of what is still needed.
Completion Date: Immediate
|
709.122(b)(5) LICENSURE Follow-up
709.122. Detoxification.
(b) 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.
|
Observations
Based on the review of client records, the facility failed to document follow-up information in accordance with policy and procedure in one of two discharged records.
The findings include:
Three client records were reviewed on March 30, 2010. Follow-up information was required in two discharge records. Per the facility's policy and procedure all follow-ups will be done within 90 days of clients discharge and 7 days if client is being referred.
Client record #2 was admitted on 12/10/09 and discharged on 12/10/09. The client was referred to another treatment facility with an appointment date of 12/18/09. as of the date of inspection there was no follow-up documented.
|
Plan of Correction
The Social Service staff is responsible for the follow-up calls and will be reeducated at their staff meeting on 4/21/10 as to the need and importance of follow-up phone calls. Monitoring will be done by the Medical Records Director. The Department is in a transitional period and has a temporary Director. Once the new Director is hired this will become part of his/her responsibility.
Completion Date: 4/21/10
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in one of one outpatient client record reviewed.
The finding includes:
Three records were reviewed on March 30, 2010. Treatment plan updates were required in three records reviewed.
Client #1 was admitted on 5/29/03. The client's last three treatment plan updates were documented on 4/24/09, 7/7/09 and the last one documented on 11/2/09. The treatment plan updates were not being documented every 60 days.
|
Plan of Correction
This standard and #1905 are referring to the same case. This chart was reviewed during the last BDAP survey February 25 to 27th, 2009. At this time the surveyor recommended that this case be changed to mental health as the client was no longer experiencing any drug or alcohol problems. However, this was not clearly documented in the record. This being the case, the treatment plans for mental health clients are due every 120 days. This is why there was no treatment plan from 7/7/09 to 11/2/09. Also, no case consultation was done after the last survey because it was determined that the client was being changed to mental health. This case was closed as of 12/7/09 as the client is deceased. The clinician in this case was educated regarding the need to clearly document the change from D&A to mental health in the record in the future. This will be monitored by the Director of Medical Records. This chart was only presented because we did not have any active cases and the surveyor requested a closed one.
Completion Date: Immediate
|
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document case consultations notes in one of one outpatient client record.
Findings:
Three client records were reviewed on March 30, 2010. Case consultations were required in one client record. Per the facility policy and procedure, case consultations are to be documented quarterly then after a year done annually. Case consultations notes were not documented annually in client records #1.
Client record #1 was admitted on 5/29/03. The last case consultation note was documented 2/27/08; the client was discharged on 12/7/09.
|
Plan of Correction
This standard and #1883 are referring to the same case. This chart was reviewed during the last BDAP survey February 25 to 27th, 2009. At this time the surveyor recommended that this case be changed to mental health as the client was no longer experiencing any drug or alcohol problems. However, this was not clearly documented in the record. This being the case, the treatment plans for mental health clients are due every 120 days. This is why there was no treatment plan from 7/7/09 to 11/2/09. Also, no case consultation was done after the last survey because it was determined that the client was being changed to mental health. This case was closed as of 12/7/09 as the client is deceased. The clinician in this case was educated regarding the need to clearly document the change from D&A to mental health in the record in the future. This will be monitored by the Director of Medical Records. This chart was only presented because we did not have any active cases and the surveyor requested a closed one. Completion Date: Immediate |