INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2016 and March 30, 2016 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:
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Plan of Correction
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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
Based on a review of personnel records and an interview with the Administrative Assistant/Compliance Officer/Director of Medical Records, the facility failed to document a mechanism to collect feedback on completed training in three of four personnel records as required.
The findings include:
Three personnel records requiring documentation of feedback on completed trainings were reviewed on March 29, 2016 and March 30, 2016. The facility failed to document the collection of feedback on completed trainings in personnel records # 2 and #3 and #4.
The Administrative Assistant/Compliance Officer/Director of Medical Records confirmed during an interviewed on March 30, 2016 that feedback forms were not documented on completed training.
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Plan of Correction
The Director of HR created a feedback form (MCES Training Course Evaluation Form) for use by all MCES employees when attending internal and external trainings. Employees will be required to take the evaluation form with them to a training, complete the evaluation form at the close of the course and submit the evaluation form to the HR department within 24 hours of course completion. The submitted form will be data entered and become a part of the employees training record. The evaluation form will also be included in the employees personnel file and provided during future survey visits to verify compliance. MCES has revised the Orientation and Ongoing (Annual) Education and Training Requirements policy and procedure to reflect this change. MCES will provide a copy of the evaluation form for reference upon request. The clinical supervisor in conjunction with the HR department are responsible for ensuring the corrective action plan is implemented. The clinical supervisor will ensure staff have the appropriate form and are aware of the expectation to submit completed forms to the HR department. The HR department will track form submissions and report issues to clinical supervisor for follow up with clinical staff to ensure compliance. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on the review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure at least one-half of all training was provided by trainers not directly employed by the project.
The findings include:
The Staffing Requirements Facility Summary Report form was completed by the facility on February 26, 2016. The facility failed to ensure at least one-half of all training was provided by trainers not directly employed by the project.
The Staffing Requirements Facility Summary Report revealed that more than half of the 2015 training for Employee #3 was provided in-house. Employee #3 completed 9 hours of in-house training and 2 hours of outside training.
These findings were reviewd with facility staff during the licensing process.
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Plan of Correction
MCES has contracted with Relias Learning Management Systems to provide a full spectrum of third party behavioral health related trainings to MCES employees beginning on July 1, 2016. MCES will continue to provide internal trainings and employees are also encouraged to attend additional external trainings in addition to course offerings from Relias. The clinical supervisor is responsible for ensuring clinical staff understand the expectation regarding training types and amounts and are registered for the appropriate trainings each quarter. This will be discussed and training attendance will be verified in bi monthly supervision meetings between the clinical supervisor and staff. The supervisor is responsible for ensuring staff remain in compliance by taking the appropriate trainings and that the corrective action plan is implemented. The supervisor will follow up with the HR department if issues arise and they will work together to address issues that would jeopardize compliance up to and including, staff suspension until training requirements are met or discharge for non-compliance. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the clinical supervisor.
The findings include:
The clinical supervisors personnel record was reviewed during the renewal inspection on March 29, 2016. The facility failed to document the completion of 12 clock hours of annual training for employee # 3.
Employee # 3 was hired on June 26, 1985 as the clinical supervisor. The facility's training year is from January through December. The training year for January 2015 to December 2015 was reviewed. Employee # 3 did not complete the 12 clock hours of annual training for the January 2015 to December 2015 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MCES is committed to ensuring employees receive the annual training requirement and remain in compliance. To ensure this occurs going forward, MCES has implemented quarterly training deadlines for employees. Effective July 1, 2016, employees will be required to complete a designated number of training hours each quarter, which includes internal and external trainings. Clinical staff will now be required to complete twenty (20) to twenty-five (25) hours of training annually (5-6 hours of training per quarter) including the MCES annual test, Ethics and Cultural Diversity trainings and with a minimum of twelve (12) hours of training in Co-occurring disorder (MH/D&A), recovery/resiliency training, trauma training and/or pharmacology). Non-clinical staff will now be required to complete the MCES annual test, Ethics in one (1) quarter and Cultural Diversity in one (1) quarter, as well as two (2) additional trainings within the year, one (1) per quarter. The supervisor will work with the employee to coordinate their training schedule and a review of each employees training attendance to ensure compliance.
The clinical supervisor is responsible for ensuring clinical staff understand the expectation regarding training types and amounts and are registered for the appropriate trainings each quarter. This will be discussed and training attendance and continuing training needs will be reviewed during bi-monthly supervision meetings between the clinical supervisor and staff. The supervisor is responsible for ensuring staff remain in compliance by taking the appropriate trainings and that the corrective action plan is implemented. The clinical supervisor will utilize the Relias Training System to view/print the training records of staff and monitor compliance bi-monthly. The supervisor will follow up with the HR department if issues arise and they will work together to address issues that would jeopardize compliance up to and including, staff suspension until training requirements are met or discharge for non-compliance. The Medical Director and CEO will be responsible for monitoring that the clinical supervisor is up-to-date on the required trainings.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in one of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on March 29, 2016. The facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment in one of four personnel records reviewd.
Employee #1 was hired on February 1, 2016. The instruction of staff in the use of fire extinguisher training was not documented until March 29, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 received the fire extinguisher training on March 29, 2016 during the survey visit. Documentation of training completion was provided for review to surveyors on March 29, 2016. Employees, independent contractors and temporary employees will be required to attend the MCES new hire orientation within three (3) days of date of hire/assignment. This will ensure employees receive the fire safety training upon hire and not allow this deficiency to occur again. The facility director in conjunction with the HR department will be responsible for ensuring the corrective action plan is implemented. The facility director will coordinate the hire date with the HR department who will in turn schedule the orientation for new hires. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, in one of four personnel records reviewed.
The findings include:
Four records requiring documentation that personnel on all shifts were trained to perform assigned tasks during emergencies, were reviewed on March 29, 2016.
Employee # 1 was hired on February 1, 2016. The completion of training for assigned tasks during emergencies was not documented until March 29, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 received the fire drills training on March 29, 2016 during the survey visit. Documentation of training completion was provided for review to surveyors on March 29, 2016. Employees, independent contractors and temporary employees will be required to attend the MCES new hire orientation within three (3) days of date of hire/assignment. This will ensure employees receive the fire safety training upon hire and not allow this deficiency to occur again. The facility director in conjunction with the HR department will be responsible for ensuring the corrective action plan is implemented. The facility director will coordinate the hire date with the HR department who will in turn schedule the orientation for new hires. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent for the disclosure of information in one of ten client records reviewed.
The findings included:
Ten client records requiring an informed and voluntary consent to the disclosure of information were reviewed on March 29, 2016 and March 30, 2016. The facility failed to obtain an informed and voluntary consent to release information in client record #2.
Client #2 was admitted to treatment on February 13, 2016 and was still an active client at the time of the inspection. There was no signed/dated consent to release information form for the client's funding source documented in the client record at the time of review.
This is a repeat citation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Records Director reviewed the findings of the survey and the deficiency with the Social Service and Crisis Department Directors. The Directors will review the process and policy with all supervised staff and obtain a signed acknowledgement of the requirements for confidentiality and confidential release forms from each staff member by May 17, 2016. The Safety and Quality Staff will continue to monitor the completion of confidential release forms in relation to 100% compliance goal as part of their ongoing monthly review of 30 closed charts and will report the results monthly to the Performance Improvement Committee, which includes the above directors. Any non-compliance of the policy will be addressed with the specific staff member and documented during the bi-monthly supervision process. The client was discharged the day of the survey so there was not an opportunity to have a consent form signed for the funding source. |