INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted March 19-22, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Merakey Delaware 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During an onsite licensure renewal inspection March 19-22, 2019, the failed to update delineating project policies and procedures. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Twice a year, the Project Director and Program Director will audit the polices and procedures manual and will be responsible to update all project policies and procedures as required by the regulation. The Program Director will sign off on the policy and procedure book annually to ensure that this deficiency will not re-occur. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, and 12.Client #1 was admitted on October 15, 2018 and discharged on February 14, 2019. A consent to release information to Delaware County Office of Behavioral Health and the Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to the Adult Probation/Parole, Parkway Clinical Lab, Step Father, Prospect Park Health all listed other information was to be disclosed but did not specify what the other information was to include. Client #2 was admitted on January 24, 2019 and was still an active client. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health, and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Atlantic Diagnostic Laboratories, Mercy Medical Associates of Providence, Mother, Delaware County Probation/Parole all listed other information was to be disclosed but did not specify what the other information was to include. Client #3 was admitted on May 7, 2018 and was still an active client. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health, and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Client #4 was admitted on November 15, 2018 and was discharged on January 22, 2019. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health, and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Probation/Parole, Parkway Clinical Lab, Father, Sharon Hill Family Practice all listed other information was to be disclosed but did not specify what the other information was to include. Client #5 was admitted on February 8, 2019 for and was referred to a higher level of care following an assessment. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health, indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Brother, Dr. James Minnella and Department of Public Assistance all listed other information was to be disclosed but did not specify what the other information was to include. Client #6 was admitted on May 18, 2018 and was discharged on August 4, 2018. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health, and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Probation/Parole, Parkway Clinical Lab, Father, Dr. Holly Green all listed other information was to be disclosed but did not specify what the other information was to include. Client #8 was admitted on March 4, 2019 and was still an active client. A consent to release information to Delaware County Office of Behavioral Health, Atlantic Diagnostic Laboratories, LLC, Department of Public Assistance, and Magellan Behavioral Health indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Adult Probation/Parole and mother all listed other information was to be disclosed but did not specify what the other information was to include. Client #9 was admitted on July 31, 2018 and is still an active client. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health, and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Adult Probation/Parole, Parkway Clinical Lab, Spouse, Dr. E. Hogan all listed other information was to be disclosed but did not specify what the other information was to include. Client #10 was admitted on October 26, 2018 and is still an active client. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health, Department of Human Services and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Adult Probation/Parole, Parkway Clinical Lab, Mother-in-Law, Rhee Sinae CRNP Han Folcroft Family all listed other information was to be disclosed but did not specify what the other information was to include. Client #11 was admitted on July 11, 2018 and was discharged January 10, 2019. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Adult Probation/Parole, Parkway Clinical Lab, girlfriend, PCP all listed other information was to be disclosed but did not specify what the other information was to include. Client #12 was admitted on August 3, 2018 and was discharged March 12, 2019. A consent to release information to Delaware County Office of Behavioral Health, Magellan Behavioral Health and Department of Public Assistance indicated the entire record was to be released to payer audits and quality improvement reviews.Consents to release information to Adult Probation/Parole, Parkway Clinical Lab, sister, Dr. Acri all listed other information was to be disclosed but did not specify what the other information was to include. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All intake files will be audited by the Director of Intake bi-weekly to assure that all releases of information and consents are completed only with the specific information that is to be released to the entity listed on the consent. The Director of Intake will be responsible to report to the Program Director the findings of the chart audits at Supervision to ensure this deficiency does not re-occur. |
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.
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Observations
During a review of 13 client records, one client record did not contain current informed and voluntary consent from the client for the disclosure of information in the client record.Client #13 was still an active client at the time of the March 19-22, 2019 onsite licensure renewal; the expiration date for all informed and voluntary consent forms expired on February 19, 2019.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Intake Specialists will be trained on the process of completing new consents and releases for each client at intake. Each counselor should also make sure there is an active consent before any disclosure is made to any outside entity. Additionally, the counselors will each sign an acknowledgment that they received the training. The Director of Intake and Clinical Supervisor will be responsible to complete the training to ensure this deficiency does not re-occur.
Training completed by May 22, 2019 |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
During an onsite annual licensure inspection March 19-22, 2019, the project's data collection and record keeping system did not allow for the efficient retrieval of data to measure the project's performance in relationship to its stated goals and objectives. The licensing inspector was unable to efficiently retrieve information in regard to individual service records, treatment plans, and individual progress notes.These findings were reviewed with the project during the licensing process.
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Plan of Correction
The Program Director, PQI and the Avatar support team will work together to streamline the process of retrieving all information promptly and efficiently from the Avatar System. This process will be developed during a series of phone conferences starting in May 20th of 2019. The process will be completed by the end of the fiscal year, June 2019. The Program Director and Clinical Supervisor will be responsible to ensure that this deficiency does not re-occur. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
During an onsite annual licensure inspection March 19-22, 2019, the recordkeeping system did not allow for the identification of client's admissions and discharges within a specific time frame. The facility was only able to provide a several hundred-page list of admissions and discharges after six hours of the inspection beginning. There were no separate lists that were able to be provided for admissions or discharges. As of April 28, 2018, the project has been unable to provide the number of active clients that are on their census. This was reviewed with the facility staff during the licensing process.
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Plan of Correction
A monthly list of all admissions and discharge clients will be developed by the Medical Records Supervisor. Each month, the list will be sent to the Program Director and the Clinical Supervisor to monitor the treatment center census. The development and use of monthly lists will be evidence that this deficiency will not re-occur. The Medical Records Supervisor will be responsible for the implementation of the process. The Program Director and Clinical Director will be responsible for monitoring the process. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
During an onsite annual licensure renewal inspection March 19-22, 2019 the facility failed to remove vivitrol from the medication refrigerator for two discharged clients. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All medication that is in the medication refrigerator that was prescribed to a discharged client will be returned to the distributor of the medication the following day of the former client's discharge. The medication refrigerator will be searched daily by the Medical Assistant to ensure that no discharged client's medication is left. The Medical Assistant will keep a log of all medication which is sent back to the distributor of the medication. The Program Director will be responsible to receive a copy of the log from the Medical Assistant during Supervision to ensure that this deficiency does not re-occur. Date completed: May 13, 2019 |
705.28 (c) (2) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
During an onsite licensure renewal inspection, the facility fire extinguisher inside of main door #3 was missing. It was reported to have been missing for several days by facility clients.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The fire extinguisher was replaced the day of the inspection. The Facility Director will monitor that all fire extinguishers are in place in the treatment center monthly. The Facility Director will meet with the Program Director monthly to ensure this deficiency does not re-occur.
Date completed: May 17, 2019
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
A review of fire drills from the previous twelve months was completed and found the facility failed to prepare alternate exit routes to be used during fire drills.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will note in the fire drill log which exit was used so that the Program Director and the Facility Director can make sure that alternative exits routes are used throughout the year. The Program Director and Facility Director will audit the fire drill log monthly so that this deficiency does not re-occur.
Date complete: May 17, 2019 |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
During a review of 13 client files, one client did not have current consents to treatment and was still an active client.All consents for Client #13 expired February 2019.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Each counselor will be trained on updating annually all consents as needed in a client's file. The training will include noting each client's admission date before the date arrives so that all consents are updated as to the client's wishes. The client's admission date will be added to the treatment plan grid so that counselors will be aware of when to update all consents. The Clinical Supervisor will ensure compliance with this directive during supervision with the counselor's so this deficiency does not re-occur.
Training Date: June 13, 2019 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
During a review of 13 client files, three files did not have psychosocial evaluations.Clients # 3, 9, and 12 did not have completed psychosocial evaluations, only the histories were completed. There was no clinical evaluation of the information gathered from the histories.These findings were reviewed with the facility during the licensing process.
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Plan of Correction
There will be clinical training for Intake Specialists regarding how to fully complete a psychosocial with all the information that is required and necessary to properly assess a client.
Counselors will be required to sign in to the training to ensure they receive all needed information. The Director of Intake will be responsible to monitor Psychosocial's weekly to assure this deficiency does not re-occur. Training will be done by June 13, 2019 |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
During a review of 13 client files, zero were found to be incompliance including written documentation of all three elements:* Short- and long-term goals formulated by both the client and staff.* Type and frequency of treatment and rehabilitation services.* Proposed type of support services.Client #3's individual treatment and rehabilitation plan for August 17, 2018 and September 19, 2018 were not signed by either the counselor or the client verifying they were formulated by both. Client #4's individual treatment and rehabilitation plan for December 13, 2018 was not signed by either the counselor or the client verifying they were formulated by both. Client #9's individual treatment and rehabilitation plan dated January 15, 2019, February 4, 2019, and February 27, 2019 did not list type and frequency of treatment and rehabilitation services.Client #10's individual treatment and rehabilitation plan dated December 12, 2018, January 30, 2019, and March 7, 2019 did not list type and frequency of treatment and rehabilitation services.Client #11's individual treatment and rehabilitation plan for August 18, 2018, was not signed by the client verifying the plan was formulated with the client. Client #12's individual treatment and rehabilitation plan for December 5, 2018 and January 30, 2019, were not signed by the client verifying the plan was formulated with the client. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will give a training to the counselors on how to fully complete the necessary requirements of a treatment plan. This will include the development of the treatment plan with the client including noting their treatment goals and interventions and the frequency and type of treatment services. The training will also include how each counselor can make sure that a client and the counselor electronically sign their treatment plan before leaving the treatment session in the Avatar system. Additionally, we will work with the QCO department to receive additional support to ensure this deficiency does not re-occur. The Clinical Supervisor will be responsible in supervision to discuss compliance with the treatment plan process with each counselor.
Training Date: June 6th, 2019
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709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
During a review of 13 client files, the project failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in eight files. Client #1 was admitted on October 15, 2018 and discharged on February 14, 2019. The client was in Intensive Outpatient and required to participate in two individual counseling sessions monthly, however there was only one documented individual session in their file.Client # 2 was admitted on January 24, 2019 and was still an active client during the time of the inspection. The client was in Intensive Outpatient and required to participate in two individual counseling sessions monthly, however there was only one documented individual session in their file.Client #4 was admitted on November 15, 2018 and discharged on January 22, 2019. The client was in Intensive Outpatient and required to participate in two individual counseling sessions monthly, however there was only one documented individual session in their file.Client #6 was admitted on May 18, 2018 and discharged on August 4, 2018. The client was in Intensive Outpatient and required to participate in two individual counseling sessions monthly. The client only had one documented individual session in their file.Client #8 was admitted on March 4, 2019 and was still an active client. The was no documentation of any individual counseling sessions in the client's file.Client #10 was admitted on October 26, 2018 and was still an active client at the time of the inspection. The client was in Intensive Outpatient and required to participate in two individual counseling sessions monthly. The client did not have any documented individual session in their file. Client #12 was admitted August 2, 2018 and discharged on March 12, 2019. The client was in Intensive Outpatient and required to participate in two individual counseling sessions monthly. The client only had one documented individual session in their file.Client #13 was admitted on February 2, 2018 and was still an active client at the time of the inspection. The client was in Intensive Outpatient and required to participate in two individual counseling sessions monthly. The client did not have any documented individual session in their file. These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will give a training to all counselors on the process of assuring that the clients receive the counseling sessions which are noted on the treatment plan. If a client does not attend an arranged individual session, the counselor will complete a progress note documenting the client did not attend his/her individual session as required. The Clinical Supervision will be responsible to ensure this deficiency does not re-occur.
Training Date: June 6th, 2019 |
709.93(a) 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:
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Observations
During a review of client records on March 19-22, 2019, 13 or 13 records were incomplete missing the records of services and individual progress notes.These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Program Director will work with the Avatar team to develop a tracking system for complete records of service. Until that system is created, the counselors will complete a form which will be placed inside the file regarding the records of service for the client. The counselors will monitor their caseload files in Avatar and in the paper charts for all required completed progress notes. The Clinical Supervisor will be responsible to monitor the completion of the records of service and the progress notes in Supervision with the counselors |