INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 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 Pennsylvania 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of five personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #5 was hired as a counselor assistant on August 29, 2022 and was current in that position at the time of the inspection. Employee #5 has a qualifying bachelor ' s degree but does not have the required clinical experience. Employee #5 may counsel clients only under the direct observation of a trained counselor or clinical supervisor for at least the first 6 months of employment. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. " During documented supervision there was not documentation of any direct observation and there was only documented formal case reviews on September 29, 2022, October 5, 2022, and November 4, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Clinical Supervisor will formally document case review and an additional hour of direct observation of counselor assistant once a week and identify this information within a supervision log.
Completion Date: 12/09/2022-ongoing
2.This supervision log will be provided to Program Director for review and be filed accordingly.
Completion Date: 12/09/2022-ongoing
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709.24 (a) LICENSURE Treatment/rehabilitation Management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on a review of client records, the facility failed to follow their written policy for completing case consultations every 90 days and annually thereafter in three of six applicable records reviewed.
Client #2 was admitted on June 30, 2021 and discharged on December 29, 2021. There was no documentation of a case consultation in the record.
Client #3 was admitted on January 6, 2021 and discharged on October 16, 2021. There was no documentation of a case consultation in the record.
Client #4 was admitted on August 20, 2020 and was still current at the time of the inspection. There was no documentation of an annual case consultation for November 20, 2021 documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Each counselor will review their caseload on a monthly basis with the Clinical Supervisor and/or Outpatient Director during staff member's individual supervision. As needed, a case consultation will be completed with each client every 90 days, and annually thereafter.
Completion Date: 12/09/2022-ongoing
2.Completion of the case consultations will be logged on the counselor's caseload spreadsheet.
Completion Date: 12/09/2022-ongoing
3.Ongoing monitoring of completed case consultations is conducted through monthly review by the Clinical Supervisor and Outpatient Director to ensure that all case consultations meet the requirements.
Completion Date: 12/09/2022-ongoing
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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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one record reviewed.
Client #4 was admitted on August 20, 2020 and was still current at the time of the inspection. An informed and voluntary consent to disclose information to a funding source was signed and dated by the client on April 22, 2021 and expired on April 22, 2022. An updated consent was not signed, and the Facility Director confirmed that billing continued after April 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Deficiency was corrected and an informed and voluntary consent to disclose information to a funding source was signed and dated by the client on 11/10/2022, to expire 11/09/2023. This was documented within the client's electronic health record.
Completion Date: 11/10/2022
2. All staff members will be informed during group supervision that they shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. At no time shall information be permitted to be released to any party without an informed and voluntary consent from the client for the disclosure of information contained in the client record. There should be an active release of information for all clients regarding all required parties prior to information being provided.
Completion Date: 12/09/2022-ongoing
3. All staff will complete a refresher training regarding HIPAA and Federal Statute 42 CFR will be reviewed with each counselor regarding confidentiality and consent to disclose information, and sanctions and penalties for unauthorized disclosure regarding Substance Use Disorder records, that will be filed within their training records.
Completion Date: 12/31/2022
4. Ongoing monitoring of completed releases is conducted through monthly review by the Clinical Supervisor and Outpatient Director to ensure that all releases meet the requirements through utilization of a report from our electronic health record system that notates any current releases set to expire within the following 30 days.
Completion Date: 12/09/2022-ongoing
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with a client that included written documentation of proposed type of support service in six of six applicable records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.All staff members will be informed during group supervision that all individual treatment and rehabilitation plans with a client include written documentation of proposed types of support service.
Completion Date: 12/09/2022-ongoing
2.Staff members will add a reinforcement intervention for support services detailing which support services will be included for each client.
Completion Date: 12/09/2022-ongoing
3.Ongoing monitoring of completed treatment plans will be reviewed by Clinical Supervisor prior to being sent to a doctor for review and approval to ensure that support services are identified and documented within the plan.
Completion Date: 12/09/2022-ongoing
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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.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of six applicable records reviewed.
Client #2 was admitted on June 30, 2021and discharged on December 29, 2021. Client #2 had an individual treatment and rehabilitation plan dated June 30, 2021 and the next update was due no later than August 30, 2021; however it was not documented until September 9, 2021. The next treatment plan update was due November 9, 2021, however there was no documentation of an update prior to the client ' s discharge.
Client #3 was admitted on January 6, 2021 and discharged on October 16, 2021. Client #3 had an individual treatment and rehabilitation plan dated January 6, 2021, and the next update was due March 6, 2021; however, an update was not documented until March 12, 2021. Client #3 had a treatment plan dated April 3, 2021, and the next was due June 3, 2021; however, the next update was not documented until June 9, 2021. Client #3 had a treatment plan dated July 15, 2021, and the next was due September 15, 2021; however, there was not one documented prior to discharge.
Client #4 was admitted on August 20, 2020 and was still current at the time of the inspection. Client #4 had an individual treatment and rehabilitation plan dated May 19, 2022, and the next was due by July 19, 2022; however, one wasn ' t documented until July 25, 2022.
Client #5 was admitted on June 21, 2022 and was still current at the time of the inspection. Client #5 had an individual treatment and rehabilitation plan dated July 26, 2022 and the next one was due by September 26, 2022; however, the next one wasn ' t documented until October 6, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Each counselor will review their caseload on a monthly basis with the Clinical Supervisor and/or Outpatient Director. Each client treatment plan due date will be reviewed, and when identified as needed, a treatment plan update will be completed with the client. Staff members will complete a compliance update treatment plan and review with the client upon next session if not present. If changes need to be made, they will be done in presence of client and have client sign plan at that time.
Completion Date: 12/09/2022-ongoing
2.Update of the treatment plan will be logged on the counselor's caseload spreadsheet.
Completion Date: 12/09/2022-ongoing
3.Ongoing monitoring of completed treatment plan is conducted through monthly review by the Clinical Supervisor and Outpatient Director to ensure that all treatment plans are updated at least every 30 days through utilization of a report from our electronic health record system that notates any current treatment plans set to expire within the following 30 days.
Completion Date: 12/09/2022-ongoing
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