INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on January 4-5, 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:
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Plan of Correction
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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.
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Observations
Based on one of ten 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 using a Department approved curriculum for employee # 9.Employee # 9 was hired as a counselor on September 3, 2019 and was still in this position at the time of the inspection. 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases training was due no later than September 3, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective March 2021 the Facility Director will check the BHTEN website weekly for training opportunities including HIV/Aids. If there are open classes an e-mail will be sent by the Facility Director to staff who are still in need of the training. 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 sent 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 will partner with fellow Facility Director at Merakey regarding training opportunities with AACO. |
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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the FTE counselor caseload for two counselors in the outpatient program exceeded 35 active clients.Employee # 6 was hired as a counselor on February 1, 2017 and was still acting in that position. Employee #6 was reported to have 25 hours per week devoted to their 23 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 25/40 = .625(FTE); 23/.625 = 36.8, which equals to a client/counselor ratio of 37:1.Employee # 7 was hired as a counselor on November 25, 2002 and was still acting in that position. Employee #7 was reported to have 40 hours per week devoted to their 40 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 40/40 = 1(FTE); 40/1 = 40, which equals to a client/counselor ratio of 40:1.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.This is a repeat citation from the December 18 - 20, 2019 annual inspection.
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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 March 2021 staff meeting. The Facility Director, in conjunction with clinical supervisors, will review the caseload distributions as new cases are assigned to ensure no counselor exceeds 35 active clients. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on six of ten personnel records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in the employee record. Employee # 1 was hired as the project director on March 15, 2017 and is still active in this position. No annual written individual staff performance evaluation was documented in the personnel record. Employee # 2 was hired as the facility director on November 28, 2016 and is still active in this position. No annual written individual staff performance evaluation was documented in the personnel record. Employee # 3 was hired as a counselor May 18, 2019 and promoted to clinical supervisor on May 2, 2016 and is still active in this position. No annual written individual staff performance evaluation was documented in the personnel record. Employee # 4 was hired as the facility director on June 12, 2017 and promoted to clinical supervisor on June 1, 2018 and is still active in this position. No annual written individual staff performance evaluation was documented in the personnel record. Employee # 8 was hired as a counselor on March 30, 2009 and is still active in this position. The annual written individual staff performance evaluation provided was not signed by the employee.Employee # 10 was hired as a counselor on September 16, 2019 and is still active in this position. No annual written individual staff performance evaluation was documented in the personnel record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and program director will work together to develop and follow a calendar schedule to update all Performance Evaluations. Annual Evaluations will now be s standing agenda item for review in monthly performance and quality improvement meetings. |
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
Based on one of thirteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information. Client # 3 was admitted on May 29, 2019, discharged on January 28, 2020 and readmitted on June 1, 2020 and still active at the time of the inspection. An informed and voluntary consent to disclose form to a funding source, and lab had expired on May 29, 2020. After confirmation with the facility director and review of the client record, it was established that disclosures were still occurring for the funding source and lab.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 consents and release of information can be updated. Additionally, clinical supervisors will review tools utilized by counselors in weekly supervision to ensure on-going compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on one of thirteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.Client # 2 was admitted on May 21, 2020 and discharged on December 8, 2020. An informed and voluntary consent from the client for the disclosure of information dated May 21, 2020 to a treatment facility, medical assistance, and emergency contact did not provide the information that was to be disclosed. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the December 18-20, 2019 annual inspection.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted in the thoroughness of the releases of information charts will be flagged for review and follow-up by clinical supervisor and counselor. Counselors will be re-trained as needed if releases continue to be completed incorrectly. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on one of thirteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of disclosure.Client # 2 was admitted on May 21, 2020 and discharged on December 8, 2020. An informed and voluntary consent from the client for the disclosure of information dated May 21, 2020 to a treatment facility, medical assistance, and emergency contact did not provide the purpose of disclosure.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the December 18-20, 2019 annual inspection.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted in the thoroughness of the releases of information charts will be flagged for review and follow-up by clinical supervisor and counselor. Counselors will be re-trained as needed if releases continue to be completed incorrectly. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on seven of seven patient records reviewed, the facility failed to document an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.Patient # 1 was admitted on May 25, 2007 and was still active at the time of the inspection. There was no documentation of a random urinalysis at least monthly in the patient record for the months of April, July, August, September, and October 2020.Patient # 2 was admitted on May 21, 2020 and was discharged December 8, 2020. There was no documentation of a random urinalysis at least monthly in the patient record for the months of August, September, and November 2020.Patient # 3 was admitted on June 1, 2020 and was still active at the time of the inspection. There was no documentation of a random urinalysis at least monthly in the patient record for the months of July, August, September, and December 2020.Patient #4 was admitted on September 14, 2020 and was still active at the time of the inspection. There was no documentation of an initial urinalysis or a random urinalysis at least monthly in the patient record.Patient # 5 was admitted on February 6, 2018 and was still active at the time of the inspection. There was no documentation of a random urinalysis at least monthly in the patient record for the months of September, and December 2020.Patient # 6 was admitted on February 11, 2020 and was discharged October 23, 2020. There was no documentation of a random urinalysis at least monthly in the patient record for the months of April, May, June, July, August, and September 2020.Patient # 7 was admitted on May 8, 2020 and was and was still active at the time of the inspection. The initial urinalysis did not occur until June 30, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By April 2021, Facility Director will have worked with Nursing Supervisor, Clinical Supervisor, and Intake staff on how to monitor compliance for initial and monthly UDS. Intake Staff will be held accountable for ensuring individuals submit a UDS before continuation of medical services. The EHR hold process for methadone clients will be reviewed for accuracy and nursing staff will be retrained on ensuring UDS occur as scheduled. |
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 one of seven patient records reviewed, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years.Patient # 2 was admitted on May 21, 2020 and was discharged on December 8, 2020. There was only two hours of therapy for the month of June, no hours for the month of July, thirty minutes the month of August, and one hour the month of September.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the December 18-20, 2019, and the January 8 -10, 2017 annual inspection.
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Plan of Correction
Effective 2/8/21 monthly reports of engagement/therapy hours will be reviewed with facility director and program director during monthly performance and quality improvement meetings. Counselors that consistently under engage clients without valid documented outreach attempts will receive corrective actions. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on one of seven patient records reviewed, the facility failed to provide documentation of patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient sent to the receiving facility. Patient # 6 was admitted on February 11, 2020 and transferred out on October 23, 2020. Documentation of transfer paperwork was not provided in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the March 2021 staff meeting, Facility Director will review the transfer process with staff and refer them to the Transfer Process Map for step-by-step details. During monthly chart audits, designated staff will review files of clients who were transferred to ensure transfer packet is in the charts. Charts out of compliance will be flagged for review and follow-up with management. |
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 one of seven patient records reviewed, the facility failed to provide documentation of an annual evaluation of each patient 's status being completed by the patient 's counselor and reviewed, dated and signed by the medical director. Patient # 1 was admitted on May 25, 2007 and was still active at the time of the inspection. An annual evaluation of the patient ' s status was not documented in the patient record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the March 2021 staff meeting, Facility Director will review the standard for annual evaluations by the counselor. 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. |
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.
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Observations
Based on eight of thirteen client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan to include type and frequency of treatment and rehabilitation services. Client # 2 was admitted on May 21, 2020 and was discharged on December 8, 2020. The comprehensive treatment plan developed on June 17, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 3 was admitted on June 1, 2020 and was still active at the time of the inspection. The comprehensive treatment plan developed on June 16, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 4 was admitted on September 14, 2020 and was still active at the time of the inspection. The comprehensive treatment plan developed on October 7, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 6 was admitted on February 11, 2020 and was discharged on October 23, 2020. The comprehensive treatment plan developed on February 20, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 7 was admitted on May 8, 2020 and was still active at the time of the inspection. The comprehensive treatment plan developed on May 22, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 9 was admitted on January 3, 2020 and was discharged on April 1, 2020. The comprehensive treatment plan developed on January 28, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 10 was admitted on February 10, 2020 and was discharged on December 18, 2020. The comprehensive treatment plan developed on March 4, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 11 was admitted on April 28, 2020 and was discharged on June 11, 2020. The comprehensive treatment plan developed on May 22, 2020 did not include type and frequency of treatment and rehabilitation services. Client # 12 was admitted on April 15, 2020 and was still active at the time of the inspection. The comprehensive treatment plan developed on June 7, 2020 did not include type and frequency of treatment and rehabilitation services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation will be reviewed in the March 2021 staff meeting with staff by the Facility Director. 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 and will be available for review as needed. |
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 four of thirteen client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans shall being reviewed and updated at least every 60 days. Client # 2 was admitted on May 21, 2020 and was discharged on December 8, 2020. A treatment plan update was due to be completed on November 29, 2020. The last treatment plan update occurred on September 29, 2020.Client # 8 was admitted on March 9, 2020 and was still active at the time of the inspection. A treatment plan update was due to be completed on December 19, 2020. The last treatment plan update occurred on October 19, 2020.Client # 9 was admitted on January 3, 2020 and was discharged on April 1, 2020. A treatment plan update was due to be completed on March 28, 2020. The last treatment plan occurred on January 28, 2020.Client # 10 was admitted on February 10, 2020 and was discharged on December 18, 2020. A treatment plan update was due to be completed on November 20, 2020. The last treatment plan update occurred on September 30, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning in February 2021 notification of expiring treatment plans will be sent to supervisors and program director 10 days prior to plan expiration. Supervisors and program director will notify counselors of expiring treatment plans.
Additionally counselors are expected to track treatment plans expiration dates. Counselors that continue to have late treatment plans will be issued corrective actions. |
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.
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Observations
Based on six of thirteen 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 manual. The facility policy and procedure manual indicate case consultations to occur at least quarterly for the first year of service. Client # 1 was admitted on May 25, 2020 and was still active at the time of the inspection. A case consultation was due no later than September 25, 2020. There was not a case consultation documented in the client record. Client # 2 was admitted on May 21, 2020 and was discharged on December 8, 2020. A case consultation was due no later than September 21, 2020. There was not a case consultation documented in the client record. Client # 6 was admitted on February 11, 2020 and was discharged on October 23, 2020. A case consultation was due no later than June 11, 2020. There was not a case consultation documented in the client record. Client # 7 was admitted on May 8, 2020 and was still active at the time of the inspection. A case consultation was due no later than September 8, 2020. There was not a case consultation documented in the client record. Client # 8 was admitted on March 9, 2020 and was still active at the time of the inspection. A case consultation was due no later than July 9, 2020. There was not a case consultation documented in the client record. Client # 13 was admitted on April 29, 2020 and was still active at the time of the inspection. A case consultation was due no later than August 29, 2020. There was not a case consultation documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review this standard in the March 2021 staff meeting. 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. |