INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 22, 2024 through October 23, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of annual training during the facility's July 1, 2023 through June 30, 2024 training year in one of two applicable personnel records reviewed.Employee # 4 was hired as a clinical supervisor on June 27, 2022. There was only 9 hours and 20 minutes of completed training documented in the personnel record during the reviewed training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning December 1st, the Program Director will review the Clinical Supervisors' training hours quarterly to ensure compliance of 704.11 (e)(2) annual training requirements for clinical supervisors.
The clinical supervisors will complete a minimum of 12 hours of training within the during the facility's July 1, 2024, through June 30, 2025, training year.
In addition, the Program Director will review and update the training tracker monthly to ensure that the Clinical Supervisors are assigned enough trainings to be able to complete at least 12 hours of trainings within the fiscal year. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's July 1, 2023 through June 30, 2024 training year in four of five applicable personnel records reviewed.Employee # 6 was hired as a counselor on May 10, 2023. There was 10 hours and 10 minutes of completed training documented in the personnel record during the reviewed training year.Employee # 8 was hired as a counselor on June 27, 2022. There was 13 hours and 48 minutes of completed training documented in the personnel record during the reviewed training year.Employee # 9 was hired as a counselor on June 27, 2022. There was 13 hours and 33 minutes of completed training documented in the personnel record during the reviewed training year. Employee # 10 was hired as a counselor on August 1, 2022. There was 20 hours and 28 minutes of completed training documented in the personnel record during the reviewed training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By December 1st the clinical supervisors will be trained on the annual training requirements for counselors and clinicians.
Beginning December 16th, the Clinical Supervisors will review the Counselors' training clock hours quarterly to ensure compliance with 704.11 (f)(11) annual training requirements for counselors.
In addition, the Clinical Supervisors will review and update the tracking tracker monthly ensure that the counselors are assigned enough trainings to be able to complete at least 25 clock hours of trainings within the facility's July 1, 2024, through June 30, 2025, training year.
The Counselors will complete a minimum of 25 clock hours of training within the during the facility's July 1, 2024, through June 30, 2025, training year. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of two exits on every floor, which are separated by a minimum distance of 15 feet. During the inspection, at approximately 12:15 PM on October 23, 2024, there was only one exit on the second floor of the facility. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Merakey Facilities ordered the Escape Ladder on 11/19/24. Facilities will receive and update with delivery date within 5 business days. Facilities will notify Program when confirmation is obtained of delivery date and schedule installation within 3 business days of arrival to location." |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on an administrative review, the narcotic treatment program failed to ensure narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients. During the week of June 23, 2024 through June 29, 2024, the patient census was 299 and required 29.9 physician hours; however, there were zero physician hours documented during the week. During the week of June 30, 2024 through July 6, 2024, the patient census was 293, and required 29.3 physician hours; however, there were 25 hours and 36 minutes of physician hours documented during the week. During the week of August 25, 2024 through August 31, 2024, the patient census was 288 and required 28.8 physician hours; however, there were 6 hours and 24 minutes of physician hours documented during the week. During the week of September 1, 2024 through September 7, 2024, the patient census was 289 and required 28.9 physician hours; however, there were 25 hours and 36 minutes of physician hours documented during the week. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 12/01/24, Program Director will coordinate with the Medical Director when there is foreseen inadequate physician coverage to ensure that weekly ratios are in compliance with regulatory requirements.
Physician hours will be supported by other treating Parkside physicians and documented accordingly.
Program Director and Nursing Manager triage medical staff schedules monthly to ensure adequate coverage will be provided to patients. |
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.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient record reviewed. Patient # 2 was transferred in from another narcotic treatment program and admitted on April 23, 2024 and was still active at the time of inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the client's date of admission and the date of the initial dose given. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On October 24, 2024, the Program Director created a Confirmation of Admission form to send referring programs informing the client's start date as well as the person's first medication date.
On November 7, 2024, the Intake Staff was trained on 715.20(4) requirement that 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.
Beginning 11/11/24, the Intake Staff started sending referral programs an Acceptance Letter that includes the date of admission and the date of first medication. A copy of the letter will be scanned into the EMR.
Beginning 11/11/24, the Clinical Supervisor will conduct a review once an admission has been completed. The review will be completed by using the Intake Checklist to ensure, if applicable, the letter has been sent within the 7-day timeframe. If a letter has not been sent, the Clinical Supervisor or designee will mail the letter.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in three of three applicable patient records reviewed. Patient # 1 was admitted on August 30, 2023 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on September 13, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director. Patient # 6 was admitted on June 23, 2021 and was discharged on September 30, 2024. An annual evaluation of the patient's status was due to be completed by the counselor no later than June 23, 2024; however, there was no evaluation completed prior to discharge. Patient # 7 was admitted on June 27, 2022 and was discharged on July 24, 2024. The annual evaluation of the patient's status was completed by the counselor on April 10, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director is responsible for reviewing, dating, and signing the annual evaluations submitted by the Counseling Staff.
Currently, the programs' electronic health record does not allow for the annual evaluations to be routed to the Medical Director for review, dating, and signature.
The agency's Electronic Health Record (EMR) Team has been notified of the need to ensure that the annual evaluations can be routed to the Medical Director.
The EMR team reports that the routing feature for the annual evaluations to begin going to the Medical Director will be implemented by 11/18/24. |
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 February 2024 through September 2024 unusual incident logs, the narcotic treatment program failed to file a written unusual incident report with the Department within 48 hours following a death, due to trauma, suicide, medication error or unusual circumstances.The program was notified of the offsite death of a then-active client on June 14, 2024; however, the incident was not reported to the Department until June 18, 2024. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/02/24, the clinical staff will be training on the Unusual Incident Report requirements.
All internal critical incident notifications will have a corresponding Unusual Incident reported completed in the DDAP Incident Reporting Portal within 2 business days of the incident by appropriate Management staff. Confirmation of completion for the DDAP Incident Reporting will be sent to the Program Director and Executive Director by the staff completing the report. The Executive Director will review all internal critical incident notifications and confirmation of DDAP Incident reporting to ensure DDAP incident reports have been completed.
Beginning 12/16/24, the Program Director will conduct quarterly reviews to ensure that the requirements are been followed. |