INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on January 19-21, 2021 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on two of ten applicable personnel records reviewed, the facility failed to provide documentation of staff persons and volunteers receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the regulatory timeframe for employee # 16 and 20.
Employee # 16 was hired as a counselor on September 8, 2019 and was still in this position at the time of the inspection. HIV/Aids training was due to be completed no later than September 8, 2020. HIV/Aids training was not completed until December 8, 2020.
Employee # 20 was hired as a counselor on November 4, 2019 and was still in this position at the time of the inspection. HIV/Aids training was due to be completed no later than November 4, 2020. HIV/Aids training was not completed until January 14, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning in December 2020 the Facility Director checks the BHTEN website weekly for training opportunities including HIV/Aids. If there are open classes an e-mail to sent by the Facility Director to staff who are still in need of the training. These classes close quickly due to limited number of class sizes. If staff successfully enroll that date is entered in the staff training grid maintained by the Facility Director. After completion of the course, staff submit their certificate to the Facility Director to update the training grid. Staffing grids are updated monthly and send to management to review during supervisions. The Facility Director will continue to work on communicating training opportunities for HIV/Aids on a weekly basis to ensure compliance with this regulation. The Facility Director has recently been in contact with AACO to establish a training schedule with them. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on review of The Staffing Requirements Facility Summary Report on January 19, 2021. The FTE counselor caseload for one counselor in the outpatient program exceeded 35 active clients.
Employee # 18 was hired as a counselor on July 8, 2019 and was still acting in that position. Employee #18 was reported to have 40 hours per week devoted to their 36 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 40/40 = 1 (FTE); 36/1 = 36, which equals to a client/counselor ratio of 36:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program works on a daily basis to ensure the client/counselor ratio does not exceed 35 active clients. The Facility Director will review the ratio requirements in the February 9, 2021 managers meeting. The Assistant Program Director, who assigns new admissions to caseloads, will review the caseload distributions before assigning new cases to ensure no counselor exceeds 35 active clients. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on two of sixteen client records reviewed, the facility failed to provide an informed and voluntary consent from the client for the disclosure of information to include a dated signature of the client in client records # 15 and # 16.
Client # 15 was admitted on April 23, 2019 and discharged on October 7, 2020. Informed and voluntary consent from the client for the disclosure of information to a funding source and labs did not have the dated signature of the client. After confirmation with the facility director and review of the client records, it was established that disclosures were still occurring for the funding source and lab while the client was admitted.
Client # 16 was admitted on January 7, 2020 and discharged on December 10, 2020. Informed and voluntary consent from the client for the disclosure of information to a funding source did not have the dated signature of the client. After confirmation with the facility director and review of the client records, it was established that disclosures were still occurring for the funding source while the client was admitted.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning around March 16th, 2020 due the COVID-19 pandemic the Project move to obtaining two witness signatures when a client is providing verbal consent. Project will review with the QCO department how best to obtain these signatures in a fashion that serves to project the health and safety of clients and staff. A plan will be implemented by March 1st, 2021. Additionally, the Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted designated staff will be flag the chart for follow-up via holds in the EHR so consent can be obtained. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
|
Observations
Based on one of four buprenorphine patient records reviewed, the facility failed to provide documentation verifying that the individual has reached 18 years of age prior to administration of an agent in patient record # 11.
Patient # 11 was admitted on February 19, 2020 and was discharged on April 22, 2020. There was no documentation in the patient record verifying the patient reached 18 years of age.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
Effective February 1, 2021 the Project will start reviewing charts for newly admitted clients to ensure identification has been identified. If a client does not have a photo identification the name, date of birth, and social security number provided by the PIR will be cross checked with CBH to verify the demographics they have on file are the same as the person presenting. The Project will delegate this task to the Intake Supervisor . Charts that are missing identification will be flagged for follow-up via holds in the EHR so identification can be obtained. Additionally, the Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted designated staff will flag the chart for follow-up via holds in the EHR so identification can be obtained. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on one of four buprenorphine patient records reviewed, the facility failed to provide documentation verifying the individual 's identity, including name, address and date of birth prior to administration of an agent in patient record # 11.
Patient # 11 was admitted on February 19, 2020 and was discharged on April 22, 2020. There was no documentation in the patient record verifying the individual 's identity, including name, address and date of birth.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
Effective February 1, 2021 the Project will start reviewing charts for newly admitted clients to ensure identification has been identified. If a client does not have a photo identification the name, date of birth, and social security number provided by the PIR will be cross checked with CBH to verify the demographics they have on file are the same as the person presenting. The Project will delegate this task to the Intake Supervisor. Charts that are missing identification will be flagged for follow-up via holds in the EHR so identification can be obtained. Additionally, the Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted designated staff will flag the chart for follow-up via holds in the EHR so identification can be obtained . |
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.
|
Observations
Based on one of four buprenorphine patient records reviewed, the facility failed to provide documentation of 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 and prior to the administration of an agent in patient record # 9.
Patient # 9 was admitted on June 10, 2020 and was still active at the time of the inspection. There was not documentation of a face to face determination in the patient record.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
Upon review of the chart it appears that patient record #9 switched from buprenorphine to methadone. There was no documentation substantiating the rationale for this change in modality. Effective February 1, 2021 Project will ensure that all individuals who have a change in prescribed narcotic medications have a documented review by the provider substantiating the rational for the change. This chart audit will be delegated to the Medical Office Supervisor. |
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.
|
Observations
Based on one of five applicable methadone patient records reviewed, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for maintenance in patient record # 1.
Patient # 1 was re-admitted on July 16, 2020 and was still active at the time of the inspection. There was no informed, voluntary, written consent before an agent may be administered to the patient for maintenance in the patient record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective February 1, 2021 the Project will start reviewing charts for newly admitted clients to ensure identification has been identified. The Project will delegate this task to the Intake Supervisor. Charts that are missing consent will be flagged for follow-up via holds in the EHR so consent can be obtained. Additionally, the Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted designated staff will flag the chart for follow-up via holds in the EHR so consent can be obtained. On-site personnel would assist with securing the consents and the hold will be removed from the EHR confirming task completion. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on four of four applicable methadone patient records reviewed, the facility failed to provide documentation of the facility notifying in writing to the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in patient records # 3,4,6,and 8.
Patient # 3 was transferred in on January 13, 2020 and was still active at the time of the inspection. There was no documentation in the patient record of admission and initial dose provided to the referring facility.
Patient # 4 was transferred in on December 23, 2019 and was still active at the time of the inspection. There was no documentation in the patient record of admission and initial dose provided to the referring facility.
Patient # 6 was transferred in on January 3, 2020 and was still active at the time of the inspection. There was no documentation in the patient record of admission and initial dose provided to the referring facility.
Patient # 8 was transferred in on February 20, 2020 and was discharged on May 20, 2020. There was no documentation in the patient record of admission and initial dose provided to the referring facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the DDAP inspection on January 21, 2021, Project created a "Verification of Transfer form". Facility Director reviewed this regulation with the Assistant Program Director and Intake Supervisor for immediate implementation. Effective January 22, 2021 the Project will communicate admission date to this Project and first dose verification date with this Project to a narcotic treatment program from which a client was transferred from . The Assistant Program Director will randomly audit new charts to ensure compliance. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on one of five applicable discharged patient records reviewed, the facility failed to provide a complete client record to include a discharge summary in patient record # 5.
Patient # 5 was admitted on November 27, 2019 and discharged on February 11, 2020. There was no discharge summary documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to completing discharge summaries. Counselors will be directed to review How-to videos created by the Project on when and how to complete discharge summaries as deficiencies are noted. |
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.
|
Observations
Based on one of three applicable patient records reviewed, the facility failed to provide an annual evaluation of the patient 's status, completed by the patient 's counselor and reviewed, dated and signed by the medical director in patient record # 2.
Patient # 2 was admitted on October 24, 2018 and was still active at the time of the inspection. An annual evaluation occurred on October 16, 2019 and the next annual evaluation was due to occur on October 16, 2020. There was no annual evaluation for 2020 in the patient record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 4 - 6, 2019 and the January 15 - 18, 2019 annual inspections.
|
Plan of Correction
This citation was reviewed with all managers on January 23rd, 2021 and on February 9th, 2021. Managers will be tasked to review documentation needs weekly with staff and hold staff accountable for not completing necessary documentation, such as annual evaluations, in a timely fashion. Counselors will be directed to review How-to videos created by the Project on when and how to complete annual evaluations as deficiencies are noted. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
|
Observations
Based on two of ten applicable patient records reviewed, the facility failed to review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 in patient records # 3 and 7.
Patient # 3 was admitted on January 13, 2020 and was still active at the time of the inspection. A treatment plan update occurred on March 24, 2020 and another occurred on June 9, 2020. A treatment plan update was due to occur on May 24, 2020.
Patient # 7 was admitted on November 28, 2017 and was discharged on May 13, 2020. A treatment plan update occurred on January 10, 2020 and another occurred on April 23, 2020. A treatment plan update was due to occur on March 10, 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This citation was reviewed with all managers on January 23rd, 2021 and on February 9th, 2021. Managers will be tasked to review documentation needs weekly with staff and hold staff accountable for not completing necessary documentation timely, such as treatment plan updates. Counselors will be directed to review How-to videos created by the Project on when and how to complete treatment plans as deficiencies are noted. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on four of twelve client records reviewed, the facility failed to provide a preliminary treatment and rehabilitation plan in accordance with the facility policy and procedure of a preliminary treatment and rehabilitation plan shall be developed with the doctor on the first day during intake.
Client # 9 was admitted on June 10, 2020 and was still active at the time of the inspection. There was no preliminary treatment and rehabilitation plan developed with the client during intake. A treatment and rehabilitation plan was developed with the client on July 9, 2020.
Client # 12 was admitted on January 10, 2020 and was discharged on April 27, 2020. There was no preliminary treatment and rehabilitation plan developed with the client during intake. A treatment and rehabilitation plan was developed with the client on February 11, 2020.
Client # 14 was admitted on June 26, 2020 and was still active at the time of the inspection. There was no preliminary treatment and rehabilitation plan developed with the client during intake. A treatment and rehabilitation plan was developed with the client on July 21, 2020.
Client # 16 was admitted on January 7, 2020 and was discharged on December 10, 2020. There was no preliminary treatment and rehabilitation plan developed with the client during intake. A treatment and rehabilitation plan was developed with the client on January 14, 2020.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
Effective February 1, 2021 the Project will start reviewing charts for newly admitted clients to ensure identification has been identified. The Project will delegate this task to the Intake Supervisor . Charts that are missing a treatment plan will be flagged for follow-up via holds in the EHR so treatment plan can be obtained. Additionally, the Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted designated staff will flag the chart for follow-up via holds in the EHR so a treatment can be completed. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on five of eleven applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan to include type and frequency of treatment and rehabilitation services in client records # 1, 5, 8, 9, and 11.
Client # 1 was admitted on July 16, 2020 and was still active at the time of the inspection.
A comprehensive treatment plan developed on August 11, 2020 did not include type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on November 27, 2019 and was discharged on February 11, 2020.
A comprehensive treatment plan developed on December 6, 2020 did not include type and frequency of treatment and rehabilitation services.
Client # 8 was admitted on February 20, 2020 and was discharged on May 20, 2020.
A comprehensive treatment plan developed on March 3, 2020 did not include type and frequency of treatment and rehabilitation services.
Client # 9 was admitted on June 10, 2020 and was still active at the time of the inspection.
A comprehensive treatment plan developed on August 24, 2020 did not include type and frequency of treatment and rehabilitation services.
Client # 11 was admitted on February 19, 2020 and was discharged on April 22, 2020.
A comprehensive treatment plan developed on March 9, 2020 did not include type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This citation was reviewed with all managers on January 23rd, 2021 and on February 9th, 2021. Managers will be tasked to review documentation needs weekly with staff and hold staff accountable for not writing treatment plans in a way that adheres to regulatory standards . Counselors will be directed to review How-to videos created by the Project on how to write treatment plans to standard. An additional training is scheduled for February 17th, 2021. During supervisor review if treatment plans do not meet standard they will be send back to the counselor for edits. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on six of twelve client records reviewed, the facility failed to provide a complete client record to include case consultation notes in accordance with the facility policy and procedure of quarterly for the first year of services and annually thereafter.
Client # 1 was admitted on July 16, 2020 and was still active a the time of the inspection. A case consultation was due to be completed on November 16, 2020. There was no documentation of a case consultation in the client record.
Client # 2 was admitted on October 24, 2018 and was still active a the time of the inspection. A case consultation was due to be completed on October 24, 2020. There was no documentation of a case consultation in the client record.
Client # 3 was admitted on January 13, 2020 and was still active a the time of the inspection. A case consultation was due to be completed on May 13, 2020. There was no documentation of a case consultation for May 13, 2020 in the client record.
Client # 6 was admitted on January 3, 2020 and was still active a the time of the inspection. A case consultation was completed on March 2, 2020 however, July 2020 and November 2020 were not completed.
Client # 13 was admitted on January 15, 2020 and was still active a the time of the inspection. A case consultation was due to be completed on May 15, 2020. The only case consult completed occurred September 2020.
Client # 16 was admitted on January 7, 2020 and was discharged on December 10, 2020. A case consultation was due to be completed on May 7, 2020. There was no documentation of a case consultation for May 7, 2020 in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This citation was reviewed with all managers on January 23rd, 2021 and on February 9th, 2021. Managers will be tasked to review documentation needs weekly with staff and hold staff accountable for not completing necessary documentation, such case conferences, in a timely fashion. Counselors will be directed to review How-to videos created by the Project on when and how to complete case conferences as deficiencies are noted. |
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.
|
Observations
Based on two of two applicable client records reviewed, the facility failed to provide a complete client record to include an aftercare plan in client records # 15 and 16.
Client # 15 was admitted on April 23, 2019 and was discharged on October 7, 2020. There was not an aftercare plan provided to the client upon discharge in the client record.
Client # 16 was admitted on January 7, 2019 and was discharged on December 10, 2020. There was not an aftercare plan provided to the client upon discharge in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This citation was reviewed with all managers on January 23rd, 2021 and on February 9th, 2021. Managers will be tasked to review documentation needs weekly with staff and hold staff accountable for not completing necessary documentation, such as aftercare plans. Clinical Supervisors will review in supervisions when an aftercare plan is needed to accompany a discharge. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on four of seven discharged client records reviewed, the facility failed to provide a complete client record to include follow-up information in patient records # 7, 8, 11, and 16.
Patient # 7 was admitted on November 28, 2017 and discharged on May 13, 2020. There was no follow-up information documented in the patient record.
Patient # 8 was admitted on February 20, 2020 and discharged on May 20, 2020. There was no follow-up information documented in the patient record.
Patient # 11 was admitted on February 19, 2020 and discharged on April 22, 2020. There was no follow-up information documented in the patient record.
Patient # 16 was admitted on January 7, 2020 and discharged on December 12, 2020. There was no follow-up information documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This citation was reviewed with all managers on January 23rd, 2021 and on February 9th, 2021. Managers will be tasked to review documentation needs weekly with staff and hold staff accountable for not completing necessary documentation, such as follow-up after discharge. Managers will review discharge tracker with counselors and ensure they are documenting a follow-up with discharged clients before 30-days after discharge has passed. |