INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on December 8, 2022 through December 9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in three of three applicable personnel records reviewed. Employee # 8 was hired as a counselor on August 16, 2021 and was due to have the HIV/AIDS training and the TB/STD training no later than August 16, 2022. The HIV/AIDS training was not completed until September 16, 2022 and the TB/STD training was not completed until September 19, 2022.Employee # 13 was hired as a business officer supervisor on November 26, 2020 and was due to have the TB/STD training no later than November 26, 2022. The TB/STD training was not completed at the time of the inspection.Employee # 14 was hired as an intake therapist on November 3, 2004 and was due to have the HIV/AIDS training and the TB/STD training no later than November 3, 2006. The HIV/AIDS training was not completed until December 2, 2022 and the TB/STD training was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/12/22, Facility Director met with both Clinical Supervisors to review training requirements. Facility Director will utilize a tracker to track training hours, and training completion dates. Clinical Supervisors will review training requirements with staff and will document this within their supervision note within their first year of employment. The Clinical Supervisor will request updates of training and registration during regular supervisions. Upon hire, staff will be sent a link to take the HIV/Aids training. Facility Director will continue to provide training information upon boarding and advise of a due date 30-days prior to the actual due date. Facility Director will continue to send out bi-monthly reminder emails to all staff about registering and completing all DDAP required trainings in a timely manner.
Employee #13 is registered for this training on 1/16/23. Employee #14 is registered for 1/24/23 |
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
Based on a review of the facility's December 2021 through October 2022 fire drill logs, the facility failed to ensure that their written fire drill log included the time of the drill, the exit route used and whether the fire alarm or smoke detector was operative. The March 2022 fire drill log was missing the time of the drill. Additionally, the December 2021 through February 2022 and April 2022 through October 2022 fire drill logs were missing which exit route was used during the drill. Also, the December 2021 through October 2022 fire drill logs were missing documentation that the fire alarm or smoke detector was operative during the drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will complete monthly fire drills and fire drill logs, following the completion. A calendar reminder will be utilized to ensure completion of fire drills and fire drill logs. A member of the Safety Committee will verify completion of the form prior to the form being signed off and filed. Effective date 12/21/22. |
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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.Client # 2 was admitted on April 12, 2022 and was still active at the time of the inspection. There was evidence of a disclosure to another treatment provider on April 26, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. Client # 5 was admitted on April 17, 2017 and was discharged on June 22, 2022. The release of information form to the funding source was signed by the client on April 16, 2021 and expired on April 16, 2022. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any disclosures after April 16, 2022.Client # 6 was admitted on April 13, 2020 and was discharged on July 8, 2022. The release of information form to the funding source was signed by the client on April 30, 2020 and expired on April 30, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any disclosures after April 30, 2021.This is a repeat citation from the November 16, 2021 and January 5, 2021 annual licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In January 2022, program changed the listed due date on releases of information to be a condition versus an actual date. The Facility Director met with the Clinical Supervisors on 12/12/2022 to review the expectations that releases completed prior to January 2022 are renewed after a year. Annually, counselors will review the ROIs on file to assess if any ROIs need to be updated. If necessary, the ROI will be updated, and the due date will remain a condition, rather than an actual date. A random selection of charts will be audited monthly to monitor compliance. Intake charts will also be audited to ensure that releases are being completed appropriately, and in their entirety. |
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
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in one of seven client records reviewed. Client # 1 was admitted on November 10, 2017 and was still active at the time of the inspection. The release of information form with a purpose of primary care physician was signed and dated by the client on December 16, 2021; however, the form failed to include the name of the person, agency, or organization to whom the disclosure would be made. Client # 2 was admitted on April 12, 2022 and was still active at the time of the inspection. The release of information form with a purpose of primary care physician was signed and dated by the client on April 21, 2022; however, the form failed to include the name of the person, agency, or organization to whom the disclosure would be made. Client # 3 was admitted on April 4, 2022 and was still active at the time of the inspection. The release of information form with a purpose of primary care physician was signed and dated by the client on April 4, 2022; however, the form failed to include the name of the person, agency, or organization to whom the disclosure would be made. Client # 4 was admitted on February 3, 2022 and was discharged on September 20, 2022. A blank release of information form and a release of information form with a purpose of primary care physician were signed and dated by the client on February 3, 2022; however, both forms failed to include the name of the person, agency, or organization to whom the disclosure would be made. Client # 7 was admitted on April 6, 2022 and was still active at the time of the inspection. The release of information form with a purpose of primary care physician was signed and dated by the client on April 6, 2022; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made. This is a repeat citation from the November 16, 2021 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/13/22 Facility Director and Intake Supervisor met with Intake Staff to review that specific entity information (ie: Name, address, and contact information) for the client's PCP needs to be added. Facility Director and Intake Supervisor will audit each chart, prior to being placed in medical records, to ensure that ROIs are completed efficiently, and in their entirety.
ROIs for Client #1, Client #2, and Client #3 will be completed by 1/31/23. Client #4 and #7 are no longer active. |
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
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of seven client records reviewed. Client # 3 was admitted on April 4, 2022 and was still active at the time of the inspection. The release of information form to a government agency was signed and dated by the client on April 4, 2022, but the release form failed to include the specific information to be disclosed. Client # 4 was admitted on February 3, 2022 and was discharged on September 20, 2022. A blank release of information form was signed and dated by the client and witness on February 3, 2022, but the release form failed to include the specific information to be disclosed. This is a repeat citation from the November 16, 2021, January 5, 2021, and December 20, 2019 annual licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/13/22 Facility Director and Intake Supervisor met with Intake Staff to review how to identify and document specific information that is to be disclosed. Facility Director and Intake Supervisor will audit each chart, prior to being placed in medical records, to ensure that ROIs are completed efficiently, and in its entirety.
ROI for Client #3 will be corrected by 1/31/23. Client #4 is no longer active.
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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
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in two of seven client records reviewed. Client # 3 was admitted on April 4, 2022 and was still active at the time of the inspection. The release of information form to a government agency was signed and dated by the client on April 4, 2022, but the release form failed to include the purpose of the release. Client # 4 was admitted on February 3, 2022 and was discharged on September 20, 2022. A blank release of information form was signed and dated by the client and witness on February 3, 2022, but the release form failed to include the purpose of the release. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/13/22 Facility Director and Intake Supervisor met with Intake Staff to review how to complete and document purpose of the release. Facility Director and Intake Supervisor will audit each chart, prior to being placed in medical records, to ensure that ROIs are completed efficiently, and in its entirety.
ROI for Client #3 will be corrected by 1/31/23. Client #4 is no longer active. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in two of two applicable client records reviewed.Client # 4 was admitted on February 3, 2022 and was administratively discharged on September 20, 2022. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. Client # 6 was admitted on April 13, 2020 and was administratively discharged on July 8, 2022. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/12/22, Facility Director met with Clinical Supervisors to review the process of termination. Beginning 12/12/2022, the clinical team will ensure all clients, including those who are administratively discharged, will receive a letter of termination and information for the appeal process. If the letter cannot be handed to them then a copy will be mailed to their last known address. Supervisors will ensure this is completed as they review and approve discharge documentation. A copy of the letter will be uploaded to the client's chart. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of two applicable client records reviewed.Client # 4 was admitted on February 3, 2022 and was administratively discharged on September 20, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. Client # 6 was admitted on April 13, 2020 and was administratively discharged on July 8, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/14/2022 the Facility Director received an updated administrative discharge letter to offer clients an opportunity to appeal administrative discharges. This letter was distributed to all staff and uploaded to the Standard Program Manual. Clinical Supervisors and the Facility Director will ensure this letter is used for all administrative discharges. This letter will be handed to the client or mailed to their last known address with a copy uploaded in their chart. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's December 2021 through November 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on February 24, 2022 and May 19, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Outstanding Incident Reports from 2/24/22 and 5/19/22 were submitted into the DDAP portal on 12/21/22. The Facility Director provided retraining to Clinical Supervisors on 12/21/22 of what is considered an unusual incident and reminded Supervisors to inform the Facility Director of when these Incident Reports are submitted. The Facility Director will conduct weekly reviews utilizing a report to compare incident reports submitted internally and to those submitted in the DDAP portal to ensure compliance with this regulation. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the narcotic treatment program failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to the administration of an agent in two of four applicable patient records reviewed. Patient # 2 was admitted on April 21, 2022 and was still active at the time of the inspection. There was no documentation of the verification of the client ' s identity in the record prior to the administration of an agent. Patient # 3 was admitted on April 4, 2022 and was still active at the time of the inspection. There was no documentation of an emergency contact in the record prior to the administration of an agent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/13/22 the Facility Director and Intake Supervisor met with intake staff to review ROIs that are required to be completed at the time of intake and that identification should be verified by copying identification, signing the copy and placing it in the file. It was also discussed and reviewed that if a client declines consent for an emergency contact, this must be documented within the release, and the release must remain in the chart. Facility Director and Intake Supervisor will audit each intake chart, prior to being placed in medical records, to ensure that all documentation is completed efficiently and in its entirety, including ROIs and verification of identity. During the internal audits that the Facility Director and Intake Supervisor complete, they will be ensuring that all applicable ROIs are completed and documented.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment, prior to the administration of an agent, in one of four applicable patient records reviewed.Patient # 4 was admitted on February 3, 2022 and was discharged on September 20, 2022. The record documented that the face-to-face determination was conducted on February 7, 2022; however, the patient's first dose of an agent was administered on February 5, 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/16/2022, it was reviewed with the Medical Director, Director of Nursing, and Nurse Supervisor that no clients can be medicated without first seeing the provider. Staff will work collaboratively to ensure new admissions and readmissions have seen the provider before being medicated. This will be monitored in real time by a voucher being submitted to reflect the service, which will coincide with the medication order submitted into the system. Random chart audits will be done monthly to monitor compliance. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in one of seven patient records reviewed.Patient # 4 was admitted on February 3, 2022 and was discharged on September 20, 2022. There was no documented drug screen urinalysis, in the record, for the month of June 2022.This is a repeat citation from the November 16, 2021 and January 5, 2021 annual licensing inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure clients who have urine drug screen analysis scheduled at the end of the month have this screen completed, each month nursing staff will move clients scheduled for the final three days of the month to a random earlier day of the month. This should assist with clients who may become lost to care at the end of the month and miss opportunities to complete a screen. Staff will also monitor clients and place notes in chart documented if and when a client missed a urine drug screen for any reason in any given month. Random chart audits will be done monthly to monitor compliance |
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
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in two of four applicable patient records reviewed. Patient # 2 was admitted on April 21, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of November 2021, there was 1 hour and 45 minutes of documented psychotherapy provided to the patient; during the month of October 2022, there was 30 minutes of documented psychotherapy provided to the patient; during the month of September 2022, there was 1 hour of psychotherapy provided to the patient; and during the month of August 2022, there was 30 minutes of psychotherapy provided to the patient. Patient # 3 was admitted on April 4, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of November 2021, there was 1 hour and 10 minutes of psychotherapy provided to the patient and during the month of October 2022, there was 20 minutes of psychotherapy provided to the patient. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/12/22 the Facility Director met with Clinical Supervisors to review psychotherapy requirements. Clinical staff will schedule clients accordingly to meet these requirements. If a counselor has approved time off, a plan of coverage needs to be developed to ensure clients do not miss out on services. This plan of coverage will be discussed in supervision, prior to the staff being away. If clients are not engaging in treatment, this will continue to be documented in a non-billable note, as well as discussed within individual supervision. The clinical team will also continue to offer telehealth services, in situations when telehealth is deemed applicable and supportive to the client's needs. Clinical Supervisors will monitor client compliance with attendance during regular supervisions with the therapist. Barriers with attendance will be documented by the therapist. Chart audits will be done monthly to monitor compliance. |
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 two applicable patient records reviewed. Patient # 7 was transferred in and admitted on April 6, 2022 and was still active at the time of inspection. There was no documentation in the record indicating that the transferring narcotic treatment program was notified of the 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 12/13/22 Facility Director and Intake Supervisor met with the intake department and discussed paperwork and process for transfers. An updated checklist of intake paperwork will be completed and provided to intake staff by 12/30/22. Facility Director and Intake Supervisor will audit each chart, prior to being placed in medical records, to ensure that all documentation is completed efficiently, and in its entirety. For transfer intakes the chart will be audited following intake to ensure a letter was submitted to the referring facility notifying them of client's transfer and first dose and that there is an applicable ROI to support the documentation being submitted. |
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 facility 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 one of two applicable patient records reviewed. Patient # 6 was admitted on April 13, 2020 and was still active at the time of the inspection. There was no annual evaluation of the patient's status completed by the counselor documented in the patient record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 12/12/2022, the clinical team will track deadlines on their caseload trackers. This will be reviewed in regular supervisions. When there is a change in staffing the staff will ensure that they review all recent documentation and review these timelines. If clients are inpatient or incarcerated, upon their re-instatement, the clinical team will also review trackers to ensure there isn't any expired or pending documentation that needs to be submitted immediately upon the client's return. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake process, a personal history of the client in two of four applicable client records reviewed. Client # 3 was admitted on April 4, 2022 and was still active at the time of the inspection. There was no personal history of the client documented in the record at the time of the inspection. Client # 4 was admitted on February 3, 2022 and was discharged on September 20, 2022. There was no psychosocial evaluation of the client documented in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Psychosocial history should be completed at the time of intake. It was reviewed with the Clinical team on 12/19/22 that if Psychosocial Evaluations cannot be completed at intake, they are required to complete this within 30 days of admission. Intake staff will inform the assigned counselor and clinical supervisor if it was not completed at intake, so they are aware that it needs to be completed. Clinical Supervisors will follow up and monitor timely completion of this document within individual supervision. If clients are not engaging in treatment, the clinical team must document this a non-billable note and specify this will impact the timeliness of psychosocial history completion. Clients who are not engaging in treatment will be discussed with the therapist and Clinical Supervisors during regular supervision. Monthly chart audits will also be performed to ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was submitted and approved by the Department for the November 16, 2021 and January 5, 2021 annual licensing inspections. Failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency in the December 8, 2022 through December 9, 2022 licensing inspection.A plan of correction for failing to document the name of the person, agency or organization to whom the disclosure is made on a consent to release information form was submitted and approved by the Department for the November 16, 2021, January 5, 2021 and December 20, 2019 annual licensing inspections. Failing to document the name of the person, agency or organization to whom the disclosure is made on a consent to release information form was again found to be a deficiency in the December 8, 2022 through December 9, 2022 licensing inspection.A plan of correction for failing to complete a random urinalysis at least monthly was submitted and approved by the Department for the November 16, 2021 and January 5, 2021 annual licensing inspections. Failing to complete a random urinalysis at least monthly was again found to be a deficiency in the December 8, 2022 through December 9, 2022 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure the implementation of the plans of correction as approved by DDAP by auditing intake charts for documentation prior to the chart being filed, providing follow up during supervision with Clinical Supervisors, and assessing auditing results. A QIP will be created with a PQI Specialist and this will be reviewed in routine scheduled supervisions with Clinical Supervisors. As well as reviewed in regular PQI meetings. The Regional Director/Project Director will review the QIP with the Facility Director during regular supervisions to ensure implementation. |