INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 7-8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Merakey Colmer 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. The Employee Staffing Policy is the in process of being revised to reflect the specific language that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. 12/30/2019
2. The approved policy will be reviewed with all Outpatient staff during their staff meeting. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/13/2020
3. The policy and procedure manual will be updated to reflect the updated policy. 1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Drug & Alcohol Program Manager to ensure all staff meet the requirements. 1/1/2020 - ongoing
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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
During an inspection of eight personnel records on November 7-8, 2019, the project failed to ensure that all staff persons received the required communicable disease trainings within the regulatory timeframe.Employee #1 was hired as Facility Director on August 10, 2015 and was promoted to Project Director on August 10, 2018. The personnel file did not contain documentation of the HIV/AIDS and TB/STD training at the time of the inspection. These findings were reviewed with project staff during the licensing process. This was a repeat citation from the July 17, 2018 inspection.
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Plan of Correction
Employee #1's training review was missed when reviewing training records for completeness. Moving forward, both the Facility Director and Project Director will be both included in the Drug and Alcohol Program Manager's review of required staff training hours.
Employee #1 completed HIV/ Aids Training on 12/5/2019.
Employee #1 is signed up to complete TB/Std training on 4/14/2020 (earliest available training date)
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
During a review of personnel records on November 7-8, 2019, the project failed to document the completion of twelve clock hours of annual training required for the Project Director during the facility's July 1, 2018 through June 30, 2019 training year. Employee #1 was hired as the Facility Director on August 10, 2015 and was promoted to Project Director on October 18, 2018. These findings were reviewed with project staff during the licensing process. This was a repeat citation from the July 17, 2018 licensing inspection.
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Plan of Correction
Employee #1's training review was missed when reviewing training records for completeness. Moving forward, both the Facility Director and Project Director will be both included in the Drug and Alcohol Program Manager's quarterly review of required staff training hours.
Employee #1 will meet the 12 hour annual training regulation in the next training year.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
During a review of fire drill records on November 7-8, 2019, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of an unannounced fire drill for March 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will be providing the Office Manager with a monthly to-do check list that will include fire drills to ensure that there is a reminder that an unannounced fire drill must be conducted for that month.
It is the ultimate responsibility of the Office Manager to conduct unannounced fire drills on a monthly basis so clinic staff are prepared in case there is a real fire.
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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
During a review of fire drill records on November 7-8, 2019, the facility failed to maintain a complete 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.The facility fire drill record did not include documentation of whether any problems were encountered during monthly fire drills.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the July 17, 2018 licensing inspection.
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Plan of Correction
The Project Director will submit our Fire Drill Log form to our Merakey Quality and Compliance Organization on 12/20/2019 for corporate review. While a corporate review is taking place, the Project Director added a question to the free text of the fire drill log on 12/9/19 for monthly use to ensure any problems are adequately documented and lack of problems are acknowledged. The Fire Drill Supervisor will ensure completeness of the form before signing. |
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
During a review of personnel records on November 7-8, 2019, the facility failed to document an annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee. Staff #1 was hired as Facility Director on August 10, 2015 and was promoted to Project Director on October 18, 2018. The employee file did not contain documentation of an annual staff performance evaluation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1's annual performance evaluation review will be requested on an annual basis at the same time as a review of annual program training plans and program goals which occur in June yearly.
It is the responsibility of both the Facility Director and the Project Director to ensure this corrective action is implemented. As the persons most responsible for the overall compliance with DDAP regulations, the Facility Director and Project Director will make sure this does not re-occur.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
During the review of client records on November 7-8, 2019, the project failed to 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 the name of the person, agency or organization to whom disclosure is made and was missing in two out of seven records reviewed.Client #2 was admitted on August 28, 2019 and was current at the time of the inspection. The informed and voluntary consent form for Client #2 did not include the name of the person, agency or organization to whom disclosure was to be made but instead listed "No PCP". The disclosure was signed, witnessed and dated for August 28, 2019. Client #5 was admitted on January 9, 2019 and was discharged on May 24, 2019. The informed and voluntary consent form for Client #5 did not include the name of the person, agency or organization to whom disclosure was to be made but instead listed "No PCP". The disclosure was signed, witnessed and dated for January 9, 2019. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Colmar site has adjusted the procedure for identifying a lack of a Primary Care Physician as required by our payor. A new form was developed and implemented on 12/9/2019. The Intake Coordinator, Registrar, and therapists were trained on the updated form on 12/12/2019. A Release of Information refresher training was provided to Drug and Alcohol staff during the next group supervision meeting on 12/16/19.
The Drug & Alcohol Program Manager will complete concurrent reviews to ensure the forms are completed accurately. In addition, the Drug and Alcohol Program Manager will also audit ROI's on a quarterly basis to determine they are being utilized appropriately and provide necessary training when indicated.
Our registrar will be responsible for getting current clients to sign the updated consent forms starting on Tuesday, 1/2/20.
Our registrar will also begin to start getting new clients to sign the updated consent forms on Tuesday, 1/2/20.
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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
During the review of client records on November 7-8, 2019, the project failed to 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 the specific information disclosed. The specific information disclosed was missing in two out of seven records reviewed.Client #2 was admitted on August 28, 2019 and was current at the time of the inspection. An informed and voluntary consent dated August 28, 2019 to " NO PCP " had no specific information listed for disclosure purposes, but was signed, witnessed and dated.Client #5 was admitted on January 9, 2019 and was discharged on May 24, 2019. An informed and voluntary consent dated January 9, 2019 to " NO PCP " had no specific information listed for disclosure purposes, but was signed, witnessed and dated.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Project Director has adjusted the procedure for identifying a lack of a Primary Care Physician as required by our payor. A new form was developed and implemented on 12/9/19. The Intake Coordinator, Registrar, and therapists have been trained on the updated form. A Release of Information refresher training will be provided to Drug and Alcohol staff during the next group supervision meeting on 12/16/19.
The Drug & Alcohol Program Manager will complete concurrent reviews to ensure the forms are completed accurately. In addition, the Drug and Alcohol Program Manager will also audit ROI's on a quarterly basis to determine they are being utilized appropriately and provide necessary training when indicated.
Our registrar will be responsible for getting current clients to sign the updated consent forms starting on Tuesday, 1/2/20.
Our registrar will also begin to start getting new clients to sign the updated consent forms on Tuesday, 1/2/20. |
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
During the review of client records on November 7-8, 2019, the project failed to 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 the purpose of disclosure the purpose of disclosure was missing in two out of seven records reviewed.Client #2 was admitted on August 28, 2019 and was current at the time of the inspection. An informed and voluntary consent dated August 28, 2019 to " NO PCP " did not identify the purpose of disclosure, but was signed, witnessed and dated.Client #5 was admitted on January 9, 2019 and was discharged on May 24, 2019. An informed and voluntary consent dated January 9, 2019 to " NO PCP " did not identify the purpose of disclosure, but was signed, witnessed and dated.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
NOTE:
The Project Director has adjusted the procedure for identifying a lack of a Primary Care Physician as required by our payor. A new form was developed and implemented on 12/9/2019. The Intake Coordinator, Registrar, and therapists were trained on the updated form on 12/12/2019. A Release of Information refresher training was provided to Drug and Alcohol staff during the next group supervision meeting on 12/16/19.
The Drug & Alcohol Program Manager will complete concurrent reviews to ensure the forms are completed accurately. In addition, the Drug and Alcohol Program Manager will also audit ROI's on a quarterly basis to determine they are being utilized appropriately and provide necessary training when indicated.
Our registrar will be responsible for getting current clients to sign the updated consent forms starting on Tuesday, 1/2/20.
Our registrar will also begin to start getting new clients to sign the updated consent forms on Tuesday, 1/2/20.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During a review of client records on November 7-8, 2019, the project failed to notify clients that they may not discriminate in the provision of services on the basis of ethnicity and marital status in four out of seven records reviewed. Client #2 was admitted on August 28, 2019 and was current at the time of the inspection. Client #2 was never notified that the project may not discriminate against them in the provision of services based on ethnicity and marital status. Client #3 was admitted on June 15, 2018 and was current at the time of the inspection. Client #3 was never notified that the project may not discriminate against them in the provision of services based on ethnicity and marital status. Client #4 was admitted on January 2, 2018 and was current at the time of the inspection. Client #4 was never notified that the project may not discriminate against them in the provision of services based on ethnicity and marital status. Client #7 was admitted on January 23, 2019 and was discharged on March 26, 2019. Client #7 was never notified that the project may not discriminate against them in the provision of services based on ethnicity and marital status. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On January 19, 2018 the Client's Rights Form had been updated but somehow had omitted ethnicity and marital status. The Project Director modified the Client's Rights Form on 12/9/19 to add Ethnicity and Marital Status and it was added to all current intake documentation.
The Project Director has assumed responsibility for tracking and monitoring that all new clients are receiving the new form and signing off on it.
Our Registrar will be responsible to ensure all current clients have signed off on the newly modified form beginning on Tuesday, 1/2/2020. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving physical or sexual assault by staff or a client. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents with specific language that addresses the (1) Physical assault or sexual assault by staff or a client. 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing
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709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents with specific language that addresses death or serious injury due to trauma, suicide, medication error or unusual circumstances. 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing
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709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents with specific language that addresses significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day. 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents with specific language that addresses an event at the facility requiring the presence of police, fire or ambulance personnel. 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop and implement policies and procedures to respond to unusual incidents including fire or structural damage to the facility.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents with specific language that addresses fire or structural damage to the facility. 12/30/19.
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving the outbreak of a contagious disease requiring CDC notification.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents with specific language that addresses the outbreak of a contagious disease requiring CDC notification. 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing
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709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a review of policies and procedures on November 7-8, 2019, the project failed to develop and implement procedures in the project ' s incident report policy to include reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents with specific language that addresses a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. Incident Reporting will be in compliance with state and federal confidentiality laws. 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing
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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
During a review of the unusual incident reports on November 7-8, 2019, the project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police. On January 4, 2019, there was an event at the facility requiring the presence of police personnel that was not reported to the Department. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. The Incident Reporting Policy is in the process of being revised to reflect the reporting of unusual incidents within 3 business days following an unusual incident involving an event at the facility requiring the presence of police. 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. 1/20/20
3. The policy and procedure manual will be updated to reflect the updated policy.1/1/2020
4. Ongoing Monitoring of the policy is conducted through the review of the Program Manager to ensure all staff hired are following the policy and procedure for responding to unusual incidents. 1/1/2020-ongoing |