INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on December 1, 2022 through December 2, 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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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, conducted on December 2, 2022 at approximately 9:20 AM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The client bathrooms, in the waiting area, had graffiti on the walls and doors. Additionally, there was a ceiling tile missing from the corner of the ceiling above the toilet.
This is a repeat citation from the November 9, 2021 annual licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reach out to facilities on December 2nd and again on December 13th. The graffiti in the bathrooms has been addressed and rectified. The ceiling tile will be replaced by December 16th. The Facility Director reminded the porters on December 13th that the bathrooms need to be checked every hour and reports of graffiti should be reported to designated staff. A check-list will be added to the doors of the client bathrooms for closer monitoring of the cleaning being done. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Patient # 6 was admitted on March 13, 2020 and was administratively discharged on June 20, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On December 1st, the Facility Director updated the administrative discharge letter to afford clients an opportunity to appeal administrative discharges. This letter was distributed to all staff and uploaded to the Standard Program Manual. Clinical Supervisors will ensure this letter is used for all administrative discharges. This letter will be handed to the client or mailed to their last known address with a copy uploaded within 24-hours to their chart. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's December 2021 through November 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.
There were police and/or ambulance personnel present at the facility on the following dates and were not reported to the Department: October 28, 2022, October 17, 2022, September 15, 2022, August 20, 2022, August 8, 2022, July 5, 2022, June 20, 2022, June 2, 2022, June 1, 2022 and May 25, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director provided retraining to staff responsible for completion of Unusual Incidents on December 5th. The Project Director will conduct monthly audits to ensure compliance with this regulation. This will be done by comparing the internal incidents submitting and confirming submission of Unusual Incident. The unusual incidents not submitted will be submitted by 12/30/2022. |
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 a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in one of seven patient records reviewed.
Patient # 2 was admitted on June 14, 2022 and was still active at the time of inspection. There was no documented drug screen urinalysis, in the record, for the month of August 2022.
This is a repeat citation from the November 9, 2021 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will continue to perform monthly chart audits on a random selection of charts and review results for compliance with this regulation. By December 23rd all nursing staff will be re-trained regarding the process of rescheduling urinalysis to ensure clients receive one monthly. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's December 2021 through November 2022 unusual incident logs, the facility failed to notify the Department within 48 hours of the offsite death of an active patient.
The facility was notified of the deaths of active patients on the following dates and were not reported to the Department: August 14, 2022, June 30, 2022, May 19, 2022, and May 3, 2022.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Project Director provided retraining to staff responsible for completion of Unusual Incidents on December 5th. The Project Director will conduct monthly audits to ensure compliance with this regulation. This will be done by comparing the internal incidents submitting and confirming submission of Unusual Incident. The unusual incidents not submitted will be submitted by 12/30/2022. |
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
Based on a review of client records, the facility failed to document, as part of their intake process, a psychosocial evaluation of the client in two of three applicable client records reviewed.
Client # 1 was admitted on September 20, 2022 and was still active at the time of the inspection. There was no psychosocial evaluation of the client documented in the record at the time of the inspection.
Client # 4 was admitted on February 14, 2022 and was discharged on May 6, 2022. There was no psychosocial evaluation of the client documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project management met on December 5th to discuss a plan of correction to ensure compliance with the completion of psychosocial evaluation. Intake Staff will be assigned client's psychosocial evaluations by the Intake Supervisor with a due date within seven (7) days of Intake. The Intake Supervisor will monitor completion. Monthly chart audits will also be performed to ensure compliance. |
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.
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual , which is to include follow-up information, in two of three applicable client records reviewed.
Client # 5 was admitted on April 15, 2021 and was discharged on August 30, 2022. The client record did not document follow-up information as of the date of the inspection.
Client # 7 was admitted on February 19, 2020 and was discharged on August 18, 2022. The client record did not document follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project management met on December 5th to discuss a plan of correction to ensure compliance with discharge follow-up. The due date for follow-up is listed on all therapist's/counselor's case load tracker. Clinical Supervisors will review this due date in weekly supervisions to monitor for compliance. |