INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on December 14, 2022 through December 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Parkside Recovery 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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715.9(a)(3) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain a drug use history and current drug use status of the individual in two of four patient records reviewed.Patient #1 was admitted April 22, 2019 and was active at the time of inspection. Patient #6 was admitted October 26, 2010 and was discharged September 8, 2022.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director met with the Clinical Supervisor on 1/9/23 to discuss expectation of scanning in drug use history and current drug use from previous EHR (prior to transition), to current EHR to begin 1/16/23.
The drug use history and current drug use from the previous transferring facility (if applicable), will be scanned and uploaded to the current Electronic Health Record by 2/28/23.
The Program Director will review all admissions charts completed by the intake worker to ensure that the intake worker has documented a drug use history and current drug use status of the new admission.
Patient's 1 and 6 will have an updated drug use history and current use documented in the record by 2/28/23
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure that a narcotic treatment physician made a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been dependent for at least one year in two of four patient records reviewed.Patient #1 was admitted April 22, 2019 and was active at the time of inspection. There was no documentation in the record that the physician conducted a face-to-face determination prior to the administration of an agent.Patient #6 was admitted October 26, 2010 and was discharged September 8, 2022. There was no documentation in the record that the physician conducted a face-to-face determination prior to the administration of an agent.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director met with the Clinical Supervisor on 1/9/23 to discuss expectation of scanning in the narcotic treatment physician's face to face determination of 1-year dependence from previous EHR (prior to transition), to current EHR to begin 2/28/23.
The narcotic treatment physician's face to face determination of 1-year dependence from the previous transferring facility (if applicable), will be scanned and uploaded to the current Electronic Health Record by 2/28/23.
The Nursing Supervisor (or designee) will review all admissions charts completed by the Narcotic Treatment Physicians to ensure that there is a documented face to face determination of 1- year dependence for each new admission. A mini medical audit tool will be developed/utilized to include review of the 1- year dependence.
Patient's #1 and #6 will have an updated physician's face to face determination of the 1- year dependence documented in the record by 2/28/23.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in two of four patient records reviewed. Patient #1 was admitted April 22, 2019 and was active at the time of inspection.Patient #6 was admitted October 26, 2010 and was discharged September 8, 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director met with the Clinical Supervisor on 1/9/23 to discuss expectation of scanning in the narcotic treatment consent from previous EHR (prior to transition), to current EHR to begin 2/28/23.
The narcotic treatment consent from the previous transferring facility (if applicable), will be scanned and uploaded to the current Electronic Health Record by 2/28/23.
Prior to the administration of a narcotic agent, the Nursing Staff will ensure that they have viewed the signed narcotic treatment consent, which is completed by the intake worker upon admission. Once viewed, the first dose will be administered.
The presence of the Narcotic Treatment Consent will be reviewed as part of the quarterly chart audit process to ensure compliance.
Charts 1 and 6 will review and sign a narcotic treatment consent with the counselor or record by 2/28/23.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document that each patient received an average of 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotherapy, in one of four patient records reviewed. Patient #5 was admitted into the outpatient maintenance activity on August 8, 2022 and was still active at the time of inspection. There was no documentation in the record that indicated the patient received any psychotherapy hours for the month of November 2022. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director (or designee) will run a services' received report by the 15th of each month to ensure all persons have the required amount of psychotherapy as it relates to the duration of treatment.
The process will begin by 1/23/23.
All persons who have not received the required hours by the 15th of the month, will be scheduled to ensure hours are received prior to the close of the month.
Treatment session attendance, in relation to the duration of program enrollment will be reviewed as part of the quarterly chart audit process to ensure compliance.
The Counselor of record will complete case notes documenting a patient's AWOL or lack of treatment attendance status, if the status is contributing to the lack of participation in scheduled services.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document that each patient received at least one hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of four patient records reviewed. Patient #1 was admitted into the outpatient maintenance activity on April 22, 2019 and was still active at the time of inspection. There was no documentation in the record that indicated the patient received any psychotherapy hours during the months October and November 2022.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director (or designee) will run a services' received report by the 15th of each month to ensure all persons have the required amount of psychotherapy as it relates to the duration of treatment.
The process will begin by 1/23/23.
All persons who have not received the required hours by the 15th of the month, will be scheduled to ensure hours are received prior to the close of the month.
Treatment session attendance, in relation to the duration of program enrollment will be reviewed as part of the quarterly chart audit process to ensure compliance.
The Counselor of record will complete case notes documenting a patient's AWOL or lack of treatment attendance status, if the status is contributing to the lack of participation in scheduled services.
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715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the facility failed to document a complete personal history in the patient file in two of four patient records reviewed.Patient #1 was admitted April 22, 2019 and was active at the time of inspection.Patient #6 was admitted October 26, 2010 and was discharged September 8, 2022.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director met with the Clinical Supervisor on 1/9/23 to discuss expectation of scanning in a complete personal history from previous EHR (prior to transition), to current EHR to begin 1/16/23.
The personal history from the previous transferring facility (if applicable), will be scanned and uploaded to the current Electronic Health Record by 2/28/23.
The Program Director (or designee) will review all admissions charts completed by the intake worker to ensure that the intake worker has documented a complete personal history.
Patient's #1 and #6 will have an updated personal history documented in the record by 2/28/23.
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715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Based on a review of patient records, the facility failed to document a complete medical history in the patient file in two of four patient records reviewed.Patient #1 was admitted April 22, 2019 and was active at the time of inspection.Patient #6 was admitted October 26, 2010 and was discharged September 8, 2022.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director met with the Clinical Supervisor on 1/9/23 to discuss expectation of scanning in a full medical history from previous EHR (prior to transition), to current EHR to begin 1/16/23.
The Medical history from the previous transferring facility (if applicable), will be scanned and uploaded to the current Electronic Health Record by 2/28/23.
The Nursing Supervisor (or designee) will review all admissions charts to ensure that the physician has completed a full medical history at the point of admission. Mini audit tool will be developed to include review of the medical history.
Patient #1 and #6 will have an updated medical history documented in the record by 2/28/23
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation of the patient in the patient file in two of four patient records reviewed.Patient #1 was admitted April 22, 2019 and was active at the time of inspection.Patient #6 was admitted October 26, 2010 and was discharged September 8, 2022.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The psychosocial evaluation due dates are tracked on the counselor's documentation tracker.
The Executive Director met with the Clinical Supervisor on 1/9/23 to discuss expectation of scanning in psychosocial evaluations from previous EHR (prior to transition), to current EHR to begin 1/16/23. The psychosocial from the previous transferring facility (if applicable), will be scanned and uploaded to the current Electronic Health Record by 2/28/23.
The Clinical Supervisor will review all completion dates for the psychosocial evaluations during supervision to ensure completion as required.
The Clinical Supervisor and the counselor of record will review the completion compliance during supervision sessions at least once monthly.
Patient's #1 and #6 will have an updated psychosocial documented in the record by 2/28/23
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