INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 22, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Delaware County 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
|
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.
|
Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client #2 was admitted on June 3, 2025 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
"1. The Intake Drug and Alcohol Counselor will obtain a written informed and voluntary consent from the client for the disclosure of information to the funding source for Client#2 during their next kept appointment. The signed document will be uploaded into the client's electronic health record (EHR) into the ""scanned documents"" folder.
2. The Intake Drug and Alcohol Counselor will complete written informed and voluntary consents from the clients for the disclosure of information to the funding source during the intake process and annually.
3. The Program Director will review a sample of Intake's with the Intake Drug and Alcohol counselor monthly during individual supervision. Any missing information will be addressed and documented in the supervision notes and addressed immediately." |
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.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of six applicable client records reviewed.Client #2 was admitted on February 3, 2025 and was discharged on April 29, 2025. The individual treatment and rehabilitation plan was completed on February 25, 2025 and the first update was due no later than April 26, 2025; however, the update was not completed prior to discharge. Client #6 was admitted on May 29, 2025 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 17, 2025 and the first update was due no later than August 17, 2025; however, the update was completed on August 27, 2025.Client #7 was admitted on June 3, 2025 and was active at the time of the inspection. A treatment plan update was completed on July 22, 2025 and the next update was due no later than September 22, 2025; however, the update was not completed as of the date of the inspection. This is a repeat citation from the October 16, 2024 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
"1. The Program Director will review regulatory treatment plan requirements with staff during group supervision on 11/25/25. This review will be documented as a training sheet.
2. The Program Director will continue to use an internal tracking spreadsheet to track and monitor treatment plan due dates. Upcoming treatment plans due for the month will be discussed during group supervision.
3. The Program Director will review the internal tracking spreadsheet weekly and send email reminders to staff at least two business weeks prior to the expiration on the treatment plan. This will allow additional time for staff to reschedule missed appointments or address ongoing technical issues with the treatment plan to meet regulatory timeframes.
4. The Program Director will review all ""No-Show"" Discharges prior to approval to ensure there is an updated treatment plan within 60 days prior to discharge. If the treatment plan is outdated due to the client ""no-showing"" for their appointment, the Program Director will update the treatment plan prior to the official discharge date.
5. To monitor compliance, The Program Director will continue to audit 5 charts monthly. Any missing or late treatment plans will be addressed and documented with staff through individual supervision. Progressive discipline will be enacted, as necessary." |