INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on July 2, 2024 and September 25-26, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Monongahela Valley Inc. DBA Penn Highlands Mon Valley 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of administrative records, the facility failed to ensure the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position.
Staff #3 was hired as a clinical supervisor on November 14, 2023 and is still in that position as of the date of the inspection. There is no documentation of monthly meetings between staff #3 and the supervisor.
These findings were reviewed with the facility staff during the licensing process
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Plan of Correction
TAG L 0035
704.6 Supervisory Meetings
1. The Facility Director has ultimate responsibility for the overall compliance for this plan of correction.
2. The DDAP subsequent findings were presented to Penn Highlands Mon Valley Senior Leadership team on Thursday October 3, 2024.
3. The following 704.6 Supervisor Meetings items have been addressed since the DDAP visit on Sept 26, 2024:
a. A monthly clinical supervisor evaluation supervision form has been created and Monthly documented meetings are being conducted to discuss the clinical supervisor duties and performance for the next Six months, and thereafter shall be based upon the clinical supervisors ongoing assessment and skill level.
b. Attached are the Completed September and October 2024 clinical supervision monthly meeting documentation notes.
c. Overall Completion Date: will be in Six months Feb 28 2025.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 fire drill records from November 2023 to August 2024, the facility failed to document the exit route used, the number of persons in the facility at the time of the drill, and whether the fire alarm or smoke detector was operative for all of the fire drills conducted.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
TAG P P147
705.10 (d) Fire Safety
1. The Governing Body shall provide appropriate physical resources and personnel required to meet the needs of this Fire Safety regulation by participating in monthly fire drills to meet the needs of fire safety preparedness and ensure compliance.
2. The DDAP subsequent findings were presented to Penn Highlands Mon Valley Senior Leadership team on Thursday October 3, 2024.
3. The Facility Director, Director of Engineering and Security Supervisor modified the preexisting fire drill record form to include the following the date and time of event, the amount of time it took for evacuation, the exit route used, Documenting the current patient census at the time of the fire drill, and a notes section to write feedback on any problems encountered during the fire drill event and whether the smoke detector was operative.
4. Submitting Updated Modified form for Review to meet the requirements of 705.10 (d) Current staff training is being conducted utilizing modified form and effectiveness of current emergency fire plan will be conducted following each months fire drill to further evaluate emergency response and continuous improvement.
5. Once form approved by DDAP Overall completion date will be October 30, 2024
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill records from November 2023 to August 2024, the facility failed to conduct a fire drill during sleeping hours at least every six months.
Approval to begin services was given in November 2023. A fire dill conducted during sleeping hours was due by May 2024 and was completed in June 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
TAG P P149
705.10 (d) Fire Safety
1. The Governing Body shall provide appropriate physical resources and personnel required to meet the needs of this Fire Safety regulation by participating in monthly fire drills and one off shift during sleeping hours at least one every Six months to meet the needs of fire safety preparedness and ensure compliance.
2. The DDAP subsequent findings were presented to Penn Highlands Mon Valley Senior Leadership team on Thursday October 3, 2024.
3. The Facility Director, Director of Engineering and Security Supervisor modified the preexisting fire drill record form to include the following the date and time of Fire Drill event.
4. Submitting Updated Modified form for Review to meet the requirements of 705.10 (d)
Current staff training is being conducted utilizing modified form and effectiveness of current emergency fire plan will be conducted following each month's fire drill to further evaluate emergency response and continuous improvement.
5. Once form approved by DDAP Overall completion date will be October 30, 2024
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of administrative information and patient records, the facility failed to maintain onsite a photograph of each patient which includes the patient ' s name and birth date in five of five patient records.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
TAG N M099
715.13(b) Patient Identification
1. The Facility Director, Regional Information Technology Site Manager and the Patient Access Registration Manager will have the overall responsibility for compliance for this plan of correction.
2. The DDAP subsequent findings were presented to Penn Highlands Mon Valley Senior Leadership team on Thursday October 3, 2024.
3. The following 715.13 (b) items have been addressed since the visit on September 26, 2024:
a. The Facility Director, the Regional Information Technology Site Manager and Patient Access Registration Manager developed, trained and implemented a new registration process during the admission intake process for patients entering into the Substance Recovery Unit Program at Penn Highlands Mon Valley for both withdrawal management and rehabilitation patients.
b. A digital photo will be obtained during admission registration process in the emergency department registration area. The digital photo will then be uploaded and merged into the substance recovery patient's confidential electronic health record for verification including name and date of birth for the substance recovery unit staff to properly identify the patient for the unit and potential medication administration and or other treatment modalities.
c. The digital photo will have a date recorded in the electronic health record to meet the standard of within the last Three years.
d. The facility director will monitor compliance by conducting weekly chart reviews to ensure photos are present and visual in the patient's electronic health record for the purpose patient identification.
e. Overall Completion Date : October 30, 2024.
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