INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12-13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
1. The Employee Staffing Policy is in the process of being revised to reflect the specific language that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record. Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring of the policy is conducted through the review of the Program Director and Credentialing Director to ensure all staff hired meet the requirements.
Completion date - 1/1/20 - ongoing
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving physical or sexual assault by staff or a client. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Management and Reporting Policy is in the process of being revised to reflect the specific language that addresses the response to an unusual incident involving physical or sexual assault by staff or a client.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring is conducted by the Program Director ensuring the process for unusual incidents is followed per the policy during the monthly review of incident reports in local PQI meetings.
Completion date - 1/1/20 - ongoing
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709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Management and Reporting Policy is in the process of being revised to reflect the specific language that addresses the response to an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring is conducted by the Program Director ensuring the process for unusual incidents is followed per the policy during the monthly review of incident reports in local PQI meetings.
Completion date - 1/1/20 - ongoing |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Management and Reporting Policy is in the process of being revised to reflect the specific language that addresses the response to an unusual incident involving significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring is conducted by the Program Director ensuring the process for unusual incidents is followed per the policy during the monthly review of incident reports in local PQI meetings.
Completion date - 1/1/20 - ongoing |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Management and Reporting Policy is in the process of being revised to reflect the specific language that addresses the response to an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring is conducted by the Program Director ensuring the process for unusual incidents is followed per the policy during the monthly review of incident reports in local PQI meetings.
Completion date - 1/1/20 - ongoing |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop and implement policies and procedures to respond to unusual incidents including fire or structural damage to the facility.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Management and Reporting Policy is in the process of being revised to reflect the specific language that addresses the response to an unusual incident including fire or structural damage to the facility.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring is conducted by the Program Director ensuring the process for unusual incidents is followed per the policy during the monthly review of incident reports in local PQI meetings.
Completion date - 1/1/20 - ongoing |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving the outbreak of a contagious disease requiring CDC notification.These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Management and Reporting Policy is in the process of being revised to reflect the specific language that addresses the response to an unusual incident involving the outbreak of a contagious disease requiring CDC notification.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring is conducted by the Program Director ensuring the process for unusual incidents is followed per the policy during the monthly review of incident reports in local PQI meetings.
Completion date - 1/1/20 - ongoing |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a review of policies and procedures on November 12-13, 2019, the project failed to develop and implement procedures in the project ' s incident report policy to include reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. The Incident Management and Reporting Policy is in the process of being revised to reflect the specific language that addresses the reporting mechanism utilized to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
Completion date - 12/30/19
2. The approved policy will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 1/13/20
3. The policy and procedure manual will be updated to reflect the updated policy.
Completion date - 1/1/20
4. Ongoing Monitoring is conducted by the Program Director ensuring the process for unusual incidents is followed per the policy during the monthly review of incident reports in local PQI meetings.
Completion date - 1/1/20 - ongoing
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