INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a buprenorphine monitoring inspection conducted on January 13, 2021 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:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on one of eight employee records reviewed, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level annually for employee # 1.Employee # 1 was hired as the project director on July 1, 2019. There was not an individual training plan for the 2020-2021 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All program staff will have individual training plans created upon hire and annually. The trainings will be imported in the Learning Management System, LMS, and run monthly by the Administrative Assistant and reviewed and tracked by clinical supervisor and facility director for annual completion to ensure this deficiency does not re-occur. |
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 one of eight employee records reviewed, the facility failed to provide a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics for employee # 1.Employee # 1 was hired on December 19, 2016 and promoted to the project director on July 1, 2019. There was no documentation of HIV/AIDS/TB/STD training in the employee record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from January 14, 2020 inspection.
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Plan of Correction
All program staff will complete all regulatory trainings by the mandated time lines. Clinicians will submit a copy of the training certificates to the Program Assistant and Clinical Supervisor within 48 hours of training completion. The training information will be documented on the DDAP Mandatory Training Grid as well as certificates and training date information being uploaded into the LMS. The Clinical Supervisor and Facility Director will review and track LMS transcripts monthly for annual completion of all employee trainings to ensure this deficiency does not re-occur again. Employee #1 is scheduled through the DDAP training website to take all the in the month of April 2021. |
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
Based on one of eight employee records reviewed, the facility failed to provide at least 12 clock hours of training annually as required for the project director for employee # 1.Employee # 1 was hired as the project director on July 1, 2019. There was no documentation at least 12 clock hours of training for the July 2019 to June 2020 training year in the employee record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All program staff will complete all regulatory trainings by the mandated time lines. Clinicians, Clinical Supervisor, Facility and Project Director will submit a copy of any external training certificates to the Program Assistant and Clinical Supervisor. The training information will be documented on training grid required as well as certificates and training date information being uploaded into the LMS. The clinical supervisor and facility director will review and track LMS transcripts monthly for annual completion of all employee trainings to ensure this deficiency does not re-occur again. |
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
Based on the review of eight personnel records, the facility failed to provide documentation to instruct staff in the use of the fire extinguisher for employee # 2.Employee # 2 was hired as a facility director on September 28, 2020 and was still in this position at the time of the inspection. Employee # 2 did not have fire extinguisher training at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was completed on 1/28/21. All program staff will have individual training plans created upon hire and annually to include 7 day requirement of the Fire Safety training. The trainings will be imported in the Learning Management System, LMS, and run monthly by the Administrative Assistant and reviewed and tracked by clinical supervisor and facility director for annual completion to ensure this deficiency does not re-occur. |
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
Based on the review of eight personnel records, the facility failed to provide documentation to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.Employee # 2 was hired as a facility director on September 28, 2020 and was still in this position at the time of the inspection. Employee # 2 did not have emergency training at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was completed on 1/28/21. All program staff will have individual training plans created upon hire and annually to include 7 day requirement of the Fire Safety training. The trainings will be imported in the Learning Management System, LMS, and run monthly by the Administrative Assistant and reviewed and tracked by clinical supervisor and facility director for annual completion to ensure this deficiency does not re-occur. |
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 six of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed. Client # 2 was admitted on January 22, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated January 22, 2020 to a funding source allowed for the release of the "entire record".Client # 3 was admitted on October 14, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated October 14, 2020 to a funding source allowed for the release of the "entire record".Client # 4 was admitted on January 16, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated January 16, 2020 to a funding source allowed for the release of the "entire record".Client # 5 was admitted on September 10, 2020 and was discharged on January 12, 2021. An informed and voluntary consent from the client for the disclosure of information dated September 10, 2020 to a funding source allowed for the release of the "entire record".Client # 6 was admitted on January 14, 2020 and was discharged on January 11, 2021. An informed and voluntary consent from the client for the disclosure of information dated January 14, 2020 to a funding source allowed for the release of the "entire record".Client # 7 was admitted on October 13, 2018 and was discharged on November 19, 2020. An informed and voluntary consent from the client for the disclosure of information dated October 31, 2019 to a funding source, lab, medical assistance, emergency contact, and physician did not include the specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from January 14, 2020 inspection.
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Plan of Correction
The admission and front-end business office staff will be re-trained by the facility director on the proper way to completely fill out an informed and voluntary consent form with the client during intake. The consent will be specific to what information will be disclosed. This training will take place by April 1, 2021. Completed Consents will be reviewed during documented monthly chart audits conducted by the Medical Office Supervisor and discussed at a monthly meeting with the Clinical Supervisor to ensure this deficiency does not re-occur. For clients #s 2, 3, 4, we will have their consents redone properly immediately following their first appointment after the 4/1/21 training. For clients 5, 6, and 7, if they should re-enter services, their consents will be done properly upon admission. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of disclosure.Client # 7 was admitted on October 13, 2018 and was discharged on November 19, 2020. An informed and voluntary consent from the client for the disclosure of information dated October 31, 2019 to a funding source, lab, medical assistance, emergency contact, and physician did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The admission and front-end business office staff will be re-trained by the facility director on the proper way to completely fill out an informed and voluntary consent form with the client during intake to include the Purpose of disclosure. The consent will be specific to what information will be disclosed. This training will take place by April 1, 2021. Completed Consents will be reviewed during documented monthly chart audits conducted by the Medical Office Supervisor and discussed at a monthly meeting with the Clinical Supervisor to ensure this deficiency does not re-occur. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the date, event, or condition upon which the consent will expire. Client # 7 was admitted on October 13, 2018 and was discharged on November 19, 2020. An informed and voluntary consent from the client for the disclosure of information dated October 31, 2019 to a funding source, lab, medical assistance, emergency contact, and physician did not include the date, event or condition upon which the consent will expire. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The admission and front-end business office staff will be re-trained by the facility director on the proper way to completely fill out an informed and voluntary consent form with the client during intake. The consent will be specific to what information will be disclosed. This training will take place by April 1, 2021. Completed Consents will be reviewed during documented monthly chart audits conducted by the Medical Office Supervisor will discussed the chart audit findings during the monthly meeting with the Clinical Supervisor to ensure this deficiency does not re-occur. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include documentation that a copy of the client consent was offered to the client. Client # 7 was admitted on October 13, 2018 and was discharged on November 19, 2020. An informed and voluntary consent from the client for the disclosure of information dated October 31, 2019 to a funding source, lab, medical assistance, emergency contact, and physician did not include that a copy of the client consent was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The admission and front-end business office staff will be re-trained by the facility director on the requirement to give client a copy of the consent to every client and to maintain a copy in the chart. This training will take place by April 1, 2021. The monthly chart audit review checklist will be updated to include evidence of a copy of the consent. Medical Office Supervisor the findings of the chart audit during the monthly meeting with the Clinical Supervisor to ensure this deficiency does not re-occur. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on six of six of client records reviewed, the facility failed to provide written acknowledgement by clients that they have been notified of their rights to include reasons for removing information shall be documented in the record. Client # 1 was admitted on April 8, 2020 and was still active at the time of the inspection. There was no documentation including written acknowledgement by the clients that they have been notified of their rights to include reasons for removing information shall be documented in the record. Client # 2 was admitted on January 22, 2020 and was still active at the time of the inspection. There was no documentation including written acknowledgement by the clients that they have been notified of their rights to include reasons for removing information shall be documented in the record. Client # 3 was admitted on October 14, 2020 and was still active at the time of the inspection. There was no documentation including written acknowledgement by the clients that they have been notified of their rights to include reasons for removing information shall be documented in the record. Client # 4 was admitted on January 16, 2020 and was still active at the time of the inspection. There was no documentation including written acknowledgement by the clients that they have been notified of their rights to include reasons for removing information shall be documented in the record. Client # 5 was admitted on September 10, 2020 and was discharged on January 12, 2021. There was no documentation including written acknowledgement by the clients that they have been notified of their rights to include reasons for removing information shall be documented in the record. Client # 6 was admitted on January 14, 2020 and was discharged on January 11, 2021. There was no documentation including written acknowledgement by the clients that they have been notified of their rights to include reasons for removing information shall be documented in the record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from January 14, 2020 inspection.
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Plan of Correction
Clients Rights Document, which the client's will acknowledge, read and sign says, will be revised to include the required language " "The Program Director may temporarily remove portions of the record prior to the inspection by the PIR if they determine that the information may be detrimental if presented to the PIR. Reasons for removing sections shall be documented and kept on file" by the client by February 15, 2021. The project director, facility director and clinical supervisor will review the enterprise policy to ensure that they understand the requirement to document in the record the reason(s) for why particular sections of record was removed. The policy review will be completed by February 15, 2021. A acknowledgement sign off of completion will be forwarded to the Corporate Quality and Compliance Department for confirmation of policy review.
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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 one of two buprenorphine patient records reviewed, 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. Patient # 8 was admitted on October 2, 2020 and was still active at the time of the inspection. There was no documentation of a face to face and determination of addiction in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new MAT patients will have a face-to-face determination with the narcotic treatment physician to assess whether they are psychologically/physiologically dependent upon a narcotic drug. All clients will have addiction determination completed prior to admission. The physician will document the visit in the client's chart and the Medical Assistant will audit the chart immediately after the visit to make sure documentation is complete. If upon the review information is missing the Medical Assistant will follow-up with the physician within 48 hours to get any missing information completed. The Medical Assistant will meet with the Clinical Supervisor monthly to go over all new MAT charts to ensure this deficiency does not re-occur. |
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 one of two buprenorphine patient records reviewed, the facility failed to provide individualized psychotherapy services an average of 2.5 hours per month during the patient 's first 2 years for patient # 7.Patient # 7 was admitted on October 31, 2018 and discharged on November 19, 2020. In the month of October 2020 the patient only received one hour of psychotherapy. In the month of September 2020 the patient only received one and a half hours of psychotherapy and in August 2020 the patient only received one hour of psychotherapy.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from January 14, 2020 inspection.
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Plan of Correction
Clinical supervisor will track the MAT clients via an electronic service provision report to ensure that clients are getting minimally 2.5 hours of psychotherapy per month during their first 2 years of treatment. The Clinical Supervisor will follow-up with clinicians if the electronic report dictates that clients are not on track to meet this requirement. Clinicians will be required to document all miss appointments which will be audited during the monthly chart audit completed by the Clinical Supervisor. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on two of six applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan to include frequency of treatment and rehabilitation services. Client # 1 was admitted on April 8, 2020 and was still active at the time of the inspection. An individual treatment and rehabilitation plan developed with the client on May 28, 2020 did not include frequency of treatment and rehabilitation services. Client # 3 was admitted on October 14, 2020 and was still active at the time of the inspection. An individual treatment and rehabilitation plan developed with the client on November 2, 2020 did not include frequency of treatment and rehabilitation services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-training and review of the Treatment Plan Process will occur by March 15, 2021. All treatment plans will list the frequency of treatment services as applicable. The program supervisor will conduct monthly chart audits, with a chart audit checklist, and review plans with clinicians as necessary. Clinicians will also use a treatment plan checklist to ensure full completion. If a plan is missing this data, consultation will occur with that clinician. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on three of five applicable client records reviewed, the facility failed to provide a complete client record to include case consultation notes in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate case consultations to occur at least quarterly for the first year of service. Client # 1 was admitted on April 8, 2020 and was still active at the time of the inspection. A case consultation was due no later than August 8, 2020. There was not a case consultation documented in the client record. Client # 2 was admitted on January 22, 2020 and was discharged on December 8, 2020. A case consultation was due no later than May 22, 2020. There was not a case consultation documented in the client record. Client # 4 was admitted on January 16, 2020 and was discharged on October 23, 2020. A case consultation was due no later than May 16, 2020. There was not a case consultation documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training and review of the Case Consultation process will occur by March 15, 2021. Each client will have case consultation note completed at least quarterly. The clinical supervisor will conduct monthly chart audits, with a chart audit checklist, and review charts for consistent and complete case consultation notes. Clinicians will also use a checklist to ensure full completion. If a case consultation is missing or incomplete, the supervisor will review with the program staff. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on two of two applicable discharged client records reviewed, the facility failed to provide a complete client record to include an aftercare plan. Client # 6 was admitted on January 14, 2020 and was discharged on January 11, 2021. There was not an aftercare plan documented in the client record. Client # 7 was admitted on October 31, 2018 and was discharged on November 19, 2020. There was not an aftercare plan documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training and review of the Discharge/Aftercare process will occur by March 15, 2021. Each client will have an aftercare plan completed at the same time that the Comprehensive Treatment Plan is being developed by the Clinician. The Clinical Supervisor will conduct monthly chart audits, with a chart audit checklist, and review charts for complete and thorough aftercare planning. Clinicians will also use a checklist to ensure full completion. If an aftercare plan is missing or incomplete, the supervisor will review with the program staff. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on two of two applicable discharged client records reviewed, the facility failed to provide a complete client record to include a follow-up in the client record. Client # 5 was admitted on September 10, 2020 and discharged on November 2, 2020. There was no follow-up information documented in the client record. Client # 7 was admitted on October 31, 2018 and discharged on November 19, 2020. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training and review of the Discharge/Follow-Up process will occur by March 15, 2021. Each client will be sent a follow-up letter by administrative support within 7-14 days following the discharge. The clinical supervisor will conduct monthly chart audits, with a chart audit checklist, and review charts for complete and thorough follow-up post discharge. Clinicians will also use a checklist to ensure full completion. If follow up care is missing or incomplete, the supervisor will review with the program staff. |