INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 24, 2024 through October 25, 2024 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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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 facility's November 2023 through September 2024 fire drill logs, the facility failed to document the time of the drill on a fire drill log. There was a fire drill completed on February 29, 2024, but the fire drill log did not include the documentation of the time of the drill.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log will be modified by the Program Director to include AM and PM to ensure the specific time of the drill is documented accurately.
The Program Director will continue to review all completed fire drill logs to ensure all information is captured accurately.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure the narcotic treatment physician's review of dosage levels occurred at least twice a year, with each review occurring at least 2 months apart, to determine a patient's therapeutic dosage in one of five applicable patient records reviewed. Patient #2 was admitted on June 27, 2022 and was active at the time of inspection. The last, documented dosage level review was completed on October 26, 2023 and there was no documentation of another dosage level review in the record as of the date of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A med note occurred on 7/2/2024, indicating compliance with the regulation was sent to the review on 11/8/2024. The current process in place has been deemed effective.
Moving forward, the Program Director will ensure that any documentation identified that supports compliance with a regulation is provided to the reviewer at the time of the audit or during the exit interview process. The Program Director received training on this expectation on 11/14/2024.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in one of one applicable patient records reviewed. Patient #1 was admitted on April 4, 2023 and was active at the time of inspection. The annual evaluation was completed by the counselor on October 9, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
he Medical Director is responsible for reviewing, dating, and signing the annual evaluations submitted by the Counseling Staff.
At the time of the inspection programs' electronic health record did not allow for the annual evaluations to be routed to the Medical Director for review, dating, and signature.
However, this form has been updated within our EHR system to include a mandatory routing feature to this form. This became effective 11/18/24. Therefore, moving forward all annual evaluations are automatically routed to the Dr for signature prior to finalization. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven client records reviewed. Client # 1 was admitted on April 4, 2023 and was active at the time of inspection. A treatment plan update was completed on November 29, 2023 and the next update was due no later than January 29, 2024; however, the update was completed on April 15, 2024. Client # 3 was admitted on December 29, 2023 and was active at the time of inspection. A treatment plan update was completed on May 1, 2024 and the next update was due no later than July 1, 2024; however, the update was completed on July 23, 2024. Additionally, a treatment plan update was completed on July 23, 2024 and the next update was due no later than September 23, 2024; however, the update was not completed at the time of the inspection.Client # 4 was admitted on January 13, 2016 and was discharged on January 29, 2024. A treatment plan update was completed on November 17, 2023 and the next update was due no later than January 17, 2024; however, the update was not completed prior to the client's discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The following strategies will be utilized to monitor due dates, and prevent expiration:
1) The Counselors will maintain excel spreadsheets to track all treatment plan due dates. Trackers are brought to supervision in order to review documentation and timelines to ensure treatment plans are not at risk of expiring
2) Supervisor will send weekly email to therapist listing all clients that have treatment plans due within the next 15 days, in order to ensure treatment plans are not at risk of expiring
3) Monthly reports will also be provided to staff that shows all treatment plans coming due over the next 90 days.
The organization is also working with the electronic health record on notifications to alert staff when plans are coming up.
Client #3 was discharged 10/28/24 and transferred to another clinic immediately following his discharge from inpatient. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of an aftercare plan, if it is applicable, in one of two applicable client records reviewed.Client #5 was admitted on May 5, 2018 and was successfully discharged on March 22, 2024. There was no documentation of an aftercare plan in the record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has developed a checklist which captures all required items for successful and unsuccessful discharges, including the aftercare summary.
At the time of discharge, the therapist is to utilize the checklist to indicate all forms/processes have been completed. The checklist will be submitted to the Supervisor for review. If the aftercare summary was found to not have been provided to the individual, a copy will be mailed.
Ongoing monitoring will occur through quarterly internal chart audits.
This will be reviewed and a copy of the checklist will be provided to counselors during their clinical meeting scheduled for 11/18/2024.
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