INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Montgomery County 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility-submitted Staffing Requirement Facility Report and personnel files, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of six personnel records reviewed.
Employee #6 was hired as a medical assistant on January 18, 2018 and was due to have the HIV/AIDS training and the TB/STD training no later than January 18, 2020. There was no documentation in the personnel file indicating that the HIV/AIDS and TB/STD trainings were completed as of the date of the inspection.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The Project Director will complete a training plan with all project staff at the time of hire. This plan will be reviewed during monthly supervisions to ensure trainings are being completed and documented within the regulatory timeframe as per DDAP regulations. Facility Director will check bi-weekly for available trainings via Merakey's Learning Management System (LMS) and DDAP approved training sites and send training information to project staff to ensure compliance with regulatory timeframe as per DDAP regulations.
For employee #6, she successfully completed Part 1 and 2 (6 hours) of HIV/AIDS training on December 8th and 9th, 2021. Director and employee #6 will continue to seek out DDAP approved trainings to ensure her TB/STD training is completed on or before 6/30/22. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the October 2020 through October 2021 fire drill logs, the facility failed to identify, on every fire drill log completed, whether or not the fire alarm or smoke detector was operative during the drills conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Merakey Montgomery County's fire alarm system is inspected annually by a fire alarm maintenance company as contracted by the owners of 2506 LLC. Because Merakey Montgomery County is in a shared office space, fire safety systems cannot be alerted for the purposes of drills without the coordination and approval of building management. In this regard, the Executive Director of Adult Behavioral Health, Montgomery County or her designee will coordinate with building management to schedule monthly fire drills where the fire alarm or smoke detector will be manually set off during the drills. The process will include the following steps:
- Designee will notify all building occupants one day prior of the date and time of the drill via a notice at the entrance of the door and in the elevator.
- On the day of the drill, building management will notify the central station of the fire department to put the alarm system on test. This will activate the pull station as well as the horns/strobes throughout the building.
- All staff will proceed to the nearest exit door that is not affected by the emergency and exit the building
- All staff will proceed in an orderly manner to the designated evaluation point.
- All staff will remain in the area until further instructions are given to return to the building
- Upon completion of the fire drill, building management will
→ reset the pull station and the fire alarm control panel.
→ Notify the central station the drill test is completed
- Designee will complete the fire drill records form and submit for facility director to sign/approve.
- All fire drill records will be filed in fire drill log
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the October 2020 through October 2021 fire drill logs, the facility failed to set off a fire alarm or smoke detector during every fire drill conducted.
This finding was reviewed with facility staff during the licensing process
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Plan of Correction
Merakey Montgomery County's fire alarm system is inspected annually by a fire alarm maintenance company as contracted by the owners of 2506 LLC. Because Merakey Montgomery County is in a shared office space, fire safety systems cannot be alerted for the purposes of drills without the coordination and approval of building management. In this regard, the Executive Director of Adult Behavioral Health, Montgomery County or her designee will coordinate with building management to schedule monthly fire drills where the fire alarm or smoke detector will be manually set off during the drills. The process will include the following steps:
- Designee will notify all building occupants one day prior of the date and time of the drill via a notice at the entrance of the door and in the elevator.
- On the day of the drill, building management will notify the central station of the fire department to put the alarm system on test. This will activate the pull station as well as the horns/strobes throughout the building.
- All staff will proceed to the nearest exit door that is not affected by the emergency and exit the building
- All staff will proceed in an orderly manner to the designated evaluation point.
- All staff will remain in the area until further instructions are given to return to the building
- Upon completion of the fire drill, building management will
→ reset the pull station and the fire alarm control panel.
→ Notify the central station the drill test is completed
- Designee will complete the fire drill records form and submit for facility director to sign/approve.
- All fire drill records will be filed in fire drill log
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of client on release of information forms in one of seven client records reviewed.
Client #4 was admitted on October 8, 2020 and was discharged on February 17, 2021. A release of information form to a funding source was signed and dated by the witness on October 21, 2020; however, there was no documentation of the dated signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of September 2021, all drug and alcohol intakes are scheduled in person to obtain real time signatures. As part of the project, the Intake Coordinator or designee will review the intake documentation to ensure completeness e.g.: (client and witness signatures, date consent was given/expire) as per DDAP regulations. Staff will use tools provided by the Project to monitor consents to ensure compliance with regulatory timeframes as per state and DDAP regulations.
Consents are updated annually or sooner at the client's request. A master spreadsheet will be used, updated, and reviewed by the Project Director or designee monthly to monitor consent expiration dates. All consents will be updated using the following process:
- Therapists will be updated by Project Director or designee of any consents expiring within the next 30 days during individual monthly supervision.
- Therapist will schedule an outpatient therapy appointment to review and revise any/all expiring consents
- Once a consent is revised, the therapist will notify the Project Director or designee to update tracker spreadsheet.
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