INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15-18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, with the inspection also conducted for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. 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
27 Personnel records were reviewed during the licensing renewal inspection conducted on January 15-18, 2019. The facility failed to ensure that all employees received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training within the defined timeframe, using a Department-approved curriculum. This deficiency was found in employee records # 6, 9, 14, 15, 16, 18, 22, 27, and 28.
Employee # 6 was hired by the facility on March 20, 2017 and began employment as a clinical supervisor on October 16, 2017. The employee was required to complete HIV/AIDS and TB/STD trainings by no later than March 20, 2018. Documentation of this training was not found in the employee's record.
Employee # 9 was hired by the facility on February 20, 2017, as a counselor. The employee was required to complete HIV/AIDS training by no later than February 20, 2018. Documentation of this training was not found in the employee's record.
Employee # 14 was hired by the facility on August 28, 2017, as a counselor. The employee completed Department-approved HIV/AIDS and TB/STD trainings on October 19, 2018. However, these trainings were due to be completed by no later than August 28, 2018.
Employee # 15 was hired by the facility on February 13, 2017, as a counselor. The employee was required to complete HIV/AIDS and TB/STD trainings by no later than February 13, 2018. Documentation of these trainings was not found in the employee's record.
Employee # 16 was hired on November 27, 2017, as a counselor. The employee was required to complete HIV/AIDS and TB/STD training by no later than November 27, 2018. Documentation of these trainings was not found in the employee's record.
Employee # 18 was hired on May 15, 2017, as a counselor. The employee was required to complete HIV/AIDS and TB/STD trainings by no later than May 15, 2018. Documentation of these trainings was not found in the employee's record.
Employee # 22 was hired on June 13, 2016, as a counselor. The employee was required to complete TB/STD training by no later than June 13, 2017. Documentation of this training was not found in the employee's record.
Employee # 27 was hired on June 12, 2017, as a counselor. The employee was required to complete HIV/AIDS and TB/STD trainings by no later than June 12, 2018. Documentation of these trainings was not found in the employee's record.
Employee # 28 was hired on October 17, 2016, as a counselor. The employee was required to complete HIV/AIDS training by no later than October 17, 2017. The employee completed a HIV/AIDS training on January 26, 2018. However, the facility failed to provide documentation verifying that this training utilized a DDAP-approved curriculum.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection, which was completed on December 15, 2017.
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Plan of Correction
The Facility Director has formulated a system to track all employees training requirements. The Facility Director has reached out to company Training Department to discuss Merakey Parkside becoming a DDAP approved HIV/Aids and TB/STD training location. In the interim, the project will send staff prior to training due dates for HIV/Aids and TB/STDs to BTHEN. The training tracker will be reviewed on a monthly basis and this review started February 2019 and will be ongoing. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Personnel records were reviewed for the licensing renewal inspection conducted on January 15-18, 2019. The facility failed to provide adequate documentation verifying that at least one staff person with a CPR certification is onsite during all hours of the facility's operation.
The facility's hours of operation are as follows:
Monday - Friday 7:00 am - 7:00 pm
Saturday 8:00 am - 1:30 pm
Sunday 8:00 am - 11:30 am
Based on a review of personnel records, five counselors were the only pertinent employees with active CPR certifications. As this is not sufficient coverage for all hours of operation, it was requested that the facility provide additional CPR certifications for personnel. At the time of this writing, the facility has not provided the requested information.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Starting February 2019 the Facility Director has formulated a training tracking system to include CPR/First Aid training. The Facility Director will review this monthly and started this review in February 2019. The Facility Director will work to make sure staff are trained in CPR/First Aid and that all shifts have staff who are trained in CPR/First Aid. Facility Director will follow-up with staff and Training Department upon completion of these trainings to ensure a copy of their CPR/First Aid cards are maintained in their training file. |
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
Personnel records were reviewed during the licensing renewal inspection conducted on January 15-18, 2019. The project failed to ensure that the project director completed at least 12 annual training hours, for the reviewed facility training year of July 1, 2017 - June 30, 2018.
Employee # 1 was hired by the project on September 24, 2007 and began employment in the project director position on March 15, 2017. The employee required at least 12 annual training hours for the reviewed training year. Documentation in the employee's record indicated that 8.75 annual training hours were completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will work with the Project Director to make sure all staff are completing annual training hours each training year. The Facility Director will work with the Project Director on obtaining copies of trainings attended to be maintained in the training files. If staff are not completing annual training hours disciplinary actions will be given. This will begin February 2019. |
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
Personnel records were reviewed during the licensing renewal inspection conducted on January 15-18, 2019. The facility failed to ensure each counselor completed at least 25 annual training hours, for the reviewed facility training year of July 1, 2017 - June 30, 2018.
Employee # 4 was hired by the facility on October 3, 2016, as a counselor, and was then promoted to the clinical supervisor position on August 6, 2018. The employee required at least 25 annual training hours for the reviewed training year, for the counselor position. Documentation in the employee's personnel record indicated that 17.5 annual training hours were completed.
Employee # 9 was hired by the facility on February 20, 2017, as a counselor. Documentation in the employee's record indicated that 24 annual training hours were completed.
Employee # 16 was hired on November 27, 2017, as a counselor. The employee had 15 hours and 20 minutes of training documented for the annual training year.
Employee # 18 was hired on May 15, 2017, as a counselor. The employee had 18 hours and 5 minutes of training documented for the annual training year.
Employee #20 was hired on September 18, 1989, as a counselor. The employee had 23 hours of training documented for the annual training year.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspections, which were completed on November 3, 2016 and December 15, 2017.
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Plan of Correction
The Facility Director has developed a training tracking and filing system to ensure all employees are meeting annual training hours each training year. Beginning February 2019 the Facility Director reviews training files monthly and works with staff who are under hours to identify additional trainings to take/attend that are pertinent to their position with the project. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A physical plant inspection was conducted on January 17, 2019. During the licensing renewal inspection, an unmounted space heater was found in a storage closet located within the medical unit.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective January 18, 2019 all staff at the project were advised by Facility Director that space heaters are not permitted in the building. Any space heaters were advised to be removed immediately. Facility Director will work with Security team and will look for space heaters during routine daily rounds. If space heaters are identified staff will be advised they need to be removed. Facility Director will maintain responsibility that corrective action is implemented. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
During a physical site inspection, conducted on January 17, 2019, the fire extinguisher in the dispensing room was found not to be inspected or approved since November 2017.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director contact the project facilities department to have the fire extinguisher replaced, which was done on January 18, 2019. The fire extinguisher is now identified and known by facilities and will be checked on a monthly basis during routine rounds by the facilities department of the project. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Fifteen personnel records were reviewed for the licensing renewal inspection conducted on January 15-18, 2019. The facility failed to document the provision of fire extinguisher training to all newly hired staff, which is to be completed upon staff employment.
Employee # 5 was hired by the project on January 29, 2018 and began employment at this facility on August 27, 2018, as a counselor. The employee's record did not contain documentation of completed fire extinguisher training.
Employee # 10 was hired on March 5, 2018, as a counselor. The employee's record did not contain documentation of completed fire extinguisher training.
Employee # 11 was hired on August 27, 2018, as a counselor. The employee's record did not contain documentation of completed fire extinguisher training.
Employee # 17 was hired on August 27, 2018 as a counselor. The employee's record did not contain documentation of completed fire extinguisher training.
Employee # 19 was hired on November 26, 2018 as a counselor. The employee's record did not contain documentation of completed fire extinguisher training.
Employee # 25 was hired on November 12, 2018 as a counselor. The employee's record did not contain documentation of completed fire extinguisher training.
Employee # 26 was hired on October 22, 2018 as a counselor. The employee's record did not contain documentation of completed fire extinguisher training.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection, which was completed on December 15, 2017.
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Plan of Correction
Effective with new hires on January 28, 2019 the Facility Directory is obtaining copies of all new hire Orientation Paperwork which includes fire extinguisher training and is including these copies as part of the training files. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Fifteen personnel records were reviewed for the licensing renewal inspection conducted on January 15-18, 2019. The facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
Employee # 5 was hired by the project on January 29, 2018 and began employment at this facility on August 27, 2018, as a counselor. The training for assigned tasks during emergencies was not documented in the employee's record.
Employee # 10 was hired on March 5, 2018, as a counselor. The training for assigned tasks during emergencies was not documented in the employee's record.
Employee # 11 was hired on August 27, 2018, as a counselor. The training for assigned tasks during emergencies was not documented in the employee's record.
Employee # 17 was hired on August 27, 2018 as a counselor. The training for assigned tasks during emergencies was not documented in the employee's record.
Employee # 19 was hired on November 26, 2018 as a counselor. The training for assigned tasks during emergencies was not documented in the employee's record.
Employee # 25 was hired on November 12, 2018 as a counselor. The training for assigned tasks during emergencies was not documented in the employee's record.
Employee # 26 was hired on October 22, 2018 as a counselor. The training for assigned tasks during emergencies was not documented in the employee's record.
These findings were reviewed with the facility staff during the licensing process.
This was a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection, which was completed on December 15, 2017.
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Plan of Correction
Effective with new employees hired on January 28, 2019 the Facility Directory is obtaining copies of all new hire Orientation paperwork which includes documentation of training for emergency situations. The Facility Director will maintain these copies in the training files. |
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
Personnel records were reviewed for the licensing renewal inspection conducted on January 15-18, 2019. The facility failed to provide documentation of an annual performance evaluation for employees # 4 and 14. In addition, the facility failed to document the provision of a timely annual performance evaluation for employees # 9 and 15.
Employee # 4 was hired by the facility on October 3, 2016, as a counselor, and was then promoted to the clinical supervisor position on August 6, 2018. The facility failed to provide documentation of any annual performance evaluation that may have been completed for the employee following her date of hire.
Employee # 9 was hired by the facility on February 20, 2017, as a counselor. The first performance evaluation documented in the employee's record was completed on November 9, 2018.
Employee # 14 was hired by the facility on August 28, 2018, as a counselor. An annual performance evaluation was not documented in the employee's record.
Employee # 15 was hired by the facility on February 13, 2017. The first performance evaluation documented in the employee's record was completed on December 15, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Starting October 2018 the Facility Director developed a tracking system for all managers so that annual performance evaluations are updated in a timely manner. Beginning October 2018 this tool is reviewed on a monthly basis by the Facility Director and any managers who have annual performance evaluations due are sent a reminder email by Facility Director. While this tool was developed in October 2018 managers were already past due on several staff annual performance evaluations and these were reviewed during the January 2019 inspection. The Facility Director will maintain responsibility of ensuring that managers are completing staff annual performance evaluations in a timely matter by using the tracking tool implemented that is reviewed monthly. In reviewing this monthly Facility Director will be altered to what staff annual performance evaluations are due and can follow-up with those managers in weekly supervision until they are submitted. All over due evaluations were completed by January 31, 2019. |
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
Fourteen client records were reviewed for the licensing renewal inspection conducted on January 15-18, 2019. The facility failed to obtain a valid informed and voluntary consent from the client for the disclosure of information contained in the client record. In addition, the facility failed to ensure that a consent to release information did not exceed the limitations imposed in 4 Pa. Code 255.5 (b).
Client #1 was admitted on December 21, 2017 and was still active at the time of inspection. Client #1's release for the funding source expired on December 19, 2018 and there was no updated release documented in the file.
Client #2 was admitted on January 2, 2018 and was still active at the time of the inspection. Client #2's release for the funding source expired on December 28, 2018 and there was no updated release documented in the file.
Client # 3 was admitted on January 18, 2017 and was discharged on August 24, 2018. Client #3's release for the funding source expired on January 18, 2018 and there was no updated release documented in the file.
Client #4 was admitted on May 9, 2016 and was still active at the time of the inspection. Client #4's release for the funding source expired on May 4, 2017 and there was no updated release documented in the file.
Client #5 was admitted on June 5, 2015 and was still current at the time of the inspection. Client #5's release for the funding source expired on December 6, 2018 and there was no updated release documented in the file.
Client # 7 was admitted into treatment on June 30, 2017 and was still active in treatment. A consent to release information to the client's treatment funding source, a managed care agency, was not documented in the client's record.
Client # 9 was admitted into treatment on November 15, 2017 and was discharged on May 10, 2018. A consent to release information to a juvenile treatment court team, signed and dated by the client on November 15, 2017, authorized the release of the following information: a copy of the client's treatment plan and a copy of the client's assessment/evaluation.
Client # 10 was admitted into treatment on September 13, 2017 and was discharged on February 28, 2018. A consent to release information to the criminal justice system, signed and dated by the client on September 13, 2017, did not specify the date, event or condition upon which the consent would expire.
Client # 11 was admitted into treatment on February 19, 2018 and was discharged on August 9, 2018. A consent to release information to the client's treatment funding source, a managed care agency, was not documented in the client's record.
Client # 12 was admitted into treatment on March 22, 2018 and was discharged on July 5, 2018. Consent to release information forms found in the client's record only authorized the facility to obtain information from the specified agencies and organizations. The specified agencies and organizations are as follows: two managed care agencies, the criminal justice system, and a diagnostic laboratory. These consent forms were signed and dated by the client on March 22, 2018
Client # 13 was admitted into treatment on November 19, 2018 and was still active in treatment. Consents to release information to two managed care agencies, the client's treatment funding source, only authorized the facility to obtain information from these agencies. These consent forms were signed and dated by the client on November 16, 2018.
Client # 14 was admitted into treatment on April 23, 2018 and was discharged on August 31, 2018. Consents to release information to two managed care agencies and a diagnostic laboratory only authorized the facility to obtain information from these agencies. These consent forms were signed and dated by the client on April 23, 2018. In addition, documentation in the client's recorded indicated the facility had telephone correspondence with another narcotic treatment program on August 30, 2018, regarding the client's transfer to that program. A consent to release information to the other narcotic treatment program was not documented in the client's record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspections, which were completed on November 3, 2016 and December 15, 2017.
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Plan of Correction
Facility Director will oversee and ensure that Clinical Supervisors are working with therapists so that releases of information are updated on a yearly basis. This will be done through monthly chart audits selected at random by the Facility Director and audited by Supervisors. On January 23, 2019 staff were provided information specific to what can be released per 4 Pa. Code 255.5 (b) by the Facility Director. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility's administrative records were reviewed on during the licensing renewal inspection conducted on January 15-18, 2019.
Based on a review of the facility's incident reporting documentation, the facility failed to report to the Department an incident involving an alleged physical assault of a client, committed by another client. This incident occurred on October 20, 2018. The facility also failed to report to the Department events at the facility that required the presence of police and ambulance personnel. These events occurred on the following dates: January 14, 2018 and October 16, 2018.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective January 18, 2019 Facility Director is reviewing each Incident Report to check that all external reports have been made. If an external report has not been made it will be completed immediately by the initial reporter. The project received an in person training on Incident Reporting on February 11, 2019 to review the types of incidents that need to be reported both internal and external. |
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
The facility's administrative records were reviewed during the licensing renewal inspection conducted on January 15-18, 2019. Based on a review of the facility's incident reporting documentation, the failed to report to the Department events at the facility that required the presence of police and ambulance personnel. These events occurred on the following dates: January 14, 2018 and October 16, 2018. The facility also failed to report to the Departmetn events that
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective January 18, 2019 Facility Director is reviewing each Incident Report to check that all external reports have been made. If an external report has not been made it will be completed immediately by the initial reporter. The project received an in person training on Incident Reporting on February 11, 2019 to review the types of incidents that need to be reported both internal and external |
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
Eight client records were reviewed for the outpatient Methadone and Buprenorphine maintenance activity, as well as the Buprenorphine-waiver activity, on January 16-18, 2019. For client record # 1, the facility failed to document the provision of at least 2.5 hours of psychotherapy per month. For client records # 13 and 14, the facility failed to ensure that monthly psychotherapy hours provided to the client included at least 1 hour of individual psychotherapy per month
Client #1 was admitted on December 21, 2017 and was still active at the time of the inspection. Documentation in the client's record indicated that the client received less than 2.5 hours of psychotherapy for the months of August 2018, September 2018, October 2018, and November 2018.
Client # 13 was admitted into treatment on November 19, 2018 and was still active in treatment. Documentation in the client's record indicated that the client did not receive any hours of individual psychotherapy for the month of November 2018.
Client # 14 was admitted into treatment on April 23, 2018 and was discharged on August 31, 2018. Documentation in the client's record indicated that the client did not receive any hours of individual psychotherapy for the month of July 2018.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection completed on December 15, 2017.
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Plan of Correction
Effective February 2019 Clinical Supervisors are working with therapists to ensure members are meeting the minimum therapy requirement on a monthly basis. This will be reviewed via monthly chart audits selected at random by Facility Director and audited by Supervisors. Members lacking monthly required therapy will be reviewed by Supervisor and therapist in weekly supervision. Clinical staff will be reminded of therapy requirements on February 18, 2019. |
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
Six client records were reviewed for the use of Methadone and Buprenorphine in the outpatient maintenance activity on January 16-18, 2019. As a referring narcotic treatment program, the facility failed to document the transfer of all required patient files to a receiving narcotic treatment program. This deficiency was found in client records # 4 and 14.
Client #4 was admitted into treatment on January 18, 2017 and was discharged on August 24, 2018, upon transferring to another narcotic treatment program. The client's record did not contain documentation verifying the transfer of the required patient files to the receiving narcotic treatment program.
Client # 14 was admitted into treatment on April 23, 2018 and was discharged on August 31, 2018, upon transferring to another narcotic treatment program. The client's record did not contain documentation verifying the transfer of the required patient files to the receiving narcotic treatment program.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspections which were completed on November 3, 2016 and December 15, 2017.
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Plan of Correction
On February 18, 2019 Facility Director will review with Clinical staff paperwork requirements for members transferring in to program and out of program. Facility Director will advise clinical staff that all paperwork sent and received must be maintained in member's chart. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Eight client records were reviewed for the use of Methadone and Buprenorphine in the outpatient maintenance activity on January 16-18, 2019. As the transferring narcotic treatment program, the program failed to document what materials were sent to the receiving narcotic treatment program.
Client # 3 was admitted on January 18, 2018 and was discharged on August 24, 2018, due to the transfer to another narcotic treatment center. There was no documentation of any materials that were sent to the receiving narcotic treatment program.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On February 18, 2019 Facility Director will review with Clinical staff paperwork requirements for members transferring in to program and out of program. Facility Director will advise clinical staff that all paperwork sent and received must be maintained in member's chart. |
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
During the review of eight client records for the use of Methadone and Buprenorphine in the outpatient activity on January 16-18, 2019, the facility failed to document an annual evaluation of each patient's status completed by the patient's counselor and reviewed, dated and signed by the medical director.
Client # 3 was admitted on January 18, 2017and was discharged on August 24, 2018. There was no documentation of an annual evaluation completed by the counselor for client # 3.
Client # 4 was admitted on May 9, 2016 and was still active at the time of the inspection. There was no documentation of an annual evaluation completed by the counselor for client #4.
Client #5 was admitted on June 5, 2015 and was still active at the time of the inspection. There was no documentation of an annual evaluation completed by the counselor for client #5.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On a monthly basis Clinical Supervisors will review a random selection of charts as provided by Facility Director and review for annual evaluations. Any chart missing annual evaluation will be further reviewed by Supervisor of that case with assigned therapist. Assigned therapist will be given deadline to complete the annual evaluation. This has been on-going and will continue February 2019. Staff who are identified as lacking in their documentation will receive disciplinary actions. Staff will received disciplinary action if not completing documentation in a timely manner. The annual evaluation is also on a tracking tool that is reviewed with therapist by supervisor in weekly supervisions. |
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
A licensing renewal inspection was conducted on January 15-18, 2019. Seven client records were reviewed for the documentation of a psychosocial evaluation. The facility failed to document a psychosocial evaluation during the intake process for client records # 2, 12, and 14.
Client # 2 was admitted into treatment on January 2, 2018 and was still active in treatment. A psychosocial evaluation was not documented in the client's record.
Client # 12 was admitted into treatment on March 22, 2018 and was discharged on July 5, 2018. A comprehensive treatment plan was completed for the client on April 18, 2018. The psychosocial evaluation documented in the client's record was completed on April 30, 2018.
Client # 14 was admitted into treatment on April 23, 2018 and was discharged on August 31, 2018. A psychosocial evaluation was not documented in the client's record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On a monthly basis Clinical Supervisors will review a random selection of charts as provided by Facility Director and review for psychosocial evaluation. Any chart missing psychosocial evaluation will be further reviewed by Supervisor of that case with assigned therapist. Assigned therapist will be given deadline to complete the psychosocial. This audit process was re-introduced July 2018. Staff are provide a tracking sheet that includes due dates for the psychosocial evaluations which is reviewed with supervisor in weekly supervisions. Reviewing this tool and the chart audits will ensure timely completion. Staff not completing documentation timely will received disciplinary action. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
The facility failed to have a telephone number displayed conspicuously to the general public for emergency purposes.
During a physical plant inspection conducted on January 17, 2019, it was found that a telephone number was not displayed to the general public for emergency purposes.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On February 11, 2019 Facility Director confirmed via physical inspection that a telephone number is displayed for emergency purposes on a front door sign. |