INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on December 18-20, 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 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:
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
During an annual licensing inspection conducted on December 18-20, 2019, eight personnel records were reviewed. One employee in a counselor position did not have a qualifying bachelor ' s degree. Employee #4 was hired October 14, 2019 and was current in the position of counselor. The employee ' s bachelor ' s degree in broadcast journalism is not a qualifying degree for the position of a counselor. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselor's qualifications will be reviewed by our HR recruitment team, and any counselor qualification identified as deficient will disqualify the candidate. The unqualified candidate who was hired has been terminated as of 12/20/2019. |
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.
|
Observations
During an annual licensing inspection conducted on December 18-20, 2019, eight personnel records were reviewed. One of eight employees did not have a written individual training plan appropriate to that employee's skill level developed with input from the employee and the supervisor. Employee #5 was hired September 16, 2019 and was current in the position of counselor. The employee ' s training plan was not developed until November 6, 2019. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff members will develop an individualized training plan within 5 days of hire, and will be included as part of the onboarding/orientation. Clinical supervisor will be responsible for all initial training plan development. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
During an annual licensing inspection conducted on December 18-20, 2019, eight personnel records were reviewed. One of eight employees did not complete the required hours of training annually. The facility failed to ensure that the clinical supervisor completed at least 12 clock hours of training annually. Staff #2 only had four hours and twenty minutes of documented annual training. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff members will have their training hours reviewed by their supervisor during their biweekly or weekly supervision. Staff who are deficient at the end of the year will receive a corrective action plan. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
During a review of the Staffing Requirements Facility Summary Report on December 18-20, 2019, the project failed to keep FTE counselor caseloads for counseling in outpatient programs to 35 active clients. Staff #3 was hired on May 2, 2016 as a counselor supervisor and was still in that position at the time of the inspection. At the time of the inspection they were carrying a caseload of 51:1 exceeding the 35:1 client to counselor ratio. These findings were reviewed with the program during the licensing process.
|
Plan of Correction
The clinical supervisor was covering a caseload during a period of hiring. Since then, we have filled the position with a counselor.
In the future, when a clinical supervisor needs to fill in, we will increase their clinical time to ensure that they are covering the required hours. The program director will review this time weekly when a clinical supervisor needs to temporarily cover a caseload. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
During a physical site inspection on December 19, 2019, the facility failed to have hot water that did not exceed 120 degrees Fahrenheit.The downstairs woman's staff bathroom had hot water that measured 130 degrees Fahrenheit. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facilities has corrected and certified the issue, and the temperature will not exceed 115 degrees. Facilities will visit our program annually to test the water temperatures. Additionally, our internal security staff can check water temperatures monthly during rounds to ensure safe temperature. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
During a physical site inspection on December 19, 2019, the facility permitted in the facility a heater that was not permanently mounted or installed.There was a portable heater located in the doctor's office.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
All staff were retrained at the staff meeting in January on not allowing portable heaters in each person's office. The staff member who had this was retrained personally as well. Security and facilities will complete monthly reviews of offices to ensure no staff are bringing them into the facility. |
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.
|
Observations
During a licensing inspection conducted on December 18, 2019 through December 20, 2019, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in six out of nine personnel records reviewed.Employee #3 was hired on September 3, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher at the time of the inspection. Employee #4 was hired on October 14, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher at the time of the inspection. Employee #5 was hired on September 16, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher at the time of the inspection. Employee #6 was hired on September 23, 2019 and was a current employee at the time of the licensing inspection. This employee was not instructed in the use of the fire extinguisher at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Fire extinguisher training is now included in our onsite on-boarding process, and staff members are to be trained within 5 days of arrival. Staff supervisor is responsible for any training with the on-boarding. |
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.
|
Observations
During a licensing inspection conducted on December 18, 2019 through December 20, 2019, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in four out of eight personnel records reviewed. Employee #3 was hired on September 3, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until November 6, 2019.Employee #4 was hired on October 14, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until November 6, 2019.Employee #5 was hired on September 16, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies until November 6, 2019.Employee #6 was hired on September 23, 2019 and was a current employee at the time of the licensing inspection. The employee did not receive training to perform assigned tasks during emergencies.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Fire safety and emergency training will be completed within the first 5 days of being onsite and will be included in their on-boarding with their supervisor. The supervisor is responsible for ensuring all staff are trained during this period. |
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.
|
Observations
During a review of facility fire drill records on December 18-20, 2019, the facility failed to maintain a written fire drill record including the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Fire drills from January 2019 through November 2019 were missing a written fire drill record that included the exit route used, problems encountered and whether the fire alarm or smoke detector were operative. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Security staff, who is responsible for fire drills and documentation, were retrained on how to complete the newly developed forms that include all required information, such as fire alarm and smoke detector being operative, and which fire exit was used. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
|
Observations
During an interview with the facility director on December 20, 2019, the project failed to notify the Department within 90 days of a change in capacity. The project ' s capacity on the inspection date was 102 patient ' s and the project ' s capacity was only set for 90 patients.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 12/20/2019, a request to change the capacity was emailed to the state. A follow up was sent by Merakey on 2/3/2020. The program director will be responsible for monitoring the census and capacity requirements and notify the state before they are exceeded. |
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.
|
Observations
During a review of 14 client records on December 18-20, 2019, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in two client records that included the name of the person, agency or organization to whom disclosure is made. Client #7 was admitted on January 7, 2019 and was current at the time of the inspection. A consent to disclose information form dated February 18, 2019 did not include to whom disclosure was to be made. Client #11 was admitted on June 6, 2019 and was discharged on August 6, 2019. A consent to disclose information form dated June 12, 2019 did not include to whom disclosure was to be made.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All clinical and intake staff have been retrained on how to complete releases of information. Staff were also informed that incomplete releases are not valid, and staff will receive corrective action plans if they are found. Charts will be reviewed by clinical supervisor in monthly random audits. |
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.
|
Observations
During a review of 14 client records on December 18-20, 2019, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record including the specific information disclosed. Client #1 was admitted on April 25, 2019 and was still current at the time of the inspection. A consent to disclose information form, dated April 25, 2019, to an emergency contact and funding source, did not include the specific information disclosed. Client #3 was admitted on June 7, 2019 and was discharged on September 25, 2019. A consent to disclose information form, dated August 5, 2019, to an emergency contact and funding source, did not include the specific information disclosed. Client #4 was admitted on January 11, 2019 and was discharged on June 10, 2019. A consent to disclose information form, dated January 17, 2019, to an emergency contact did not include the specific information disclosed. Client #5 was admitted on May 28, 2019 and was discharged on October 11, 2019. A consent to disclose information form, dated May 28, 2019, to an emergency contact and funding source did not include the specific information disclosed. Client #7 was admitted on February 20, 2019 and was discharged on August 7, 2019. A consent to disclose information form, dated February 18, 2019, to an emergency contact, funding source and an unknown recipient did not include the specific information disclosed. Client #8 was admitted on September 23, 2019 and was still current at the time of inspection. A consent to disclose information form, dated September 23, 2019, to an emergency contact and funding source did not include the specific information disclosed. Client #11 was admitted on June 13, 2019 and was discharged on September 13, 2019. A consent to disclose information form, dated June 12, 2019, to a funding source and an unknown recipient did not include the specific information disclosed. Client #14 was admitted on August 19, 2019 and was still current at the time of the inspection. A consent to disclose information form, dated June 12, 2019, to a funding source and an emergency contact did not include the specific information disclosed. The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
All clinical and intake staff have been retrained on how to complete releases of information, and releases of information for emergency contacts. Staff were also informed that incomplete releases are not valid, and staff will receive corrective action plans if they are found. Charts will be reviewed by clinical supervisor in monthly random audits. |
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.
|
Observations
During a review of 14 client records on December 18-20, 2019, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record including the purpose of disclosure. Client #1 was admitted on April 25, 2019 and was current at the time of the inspection. A consent to disclose information form, dated April 25, 2019, to an emergency contact, a treatment facility and a funding source, did not include the purpose of disclosure. Client #2 was admitted on January 7, 2019 and was current at the time of the inspection. A consent to disclose information form, dated January 7, 2019 to a funding source, another consent to disclose information form dated January 25, 2019 to a government agency and a third consent to disclose information form dated June 27, 2019 to a specific person did not include the purpose of disclosure. Client #3 was admitted on June 7, 2019 and was discharged on September 25, 2019. A consent to disclose information form, dated August 5, 2019, to an emergency contact and funding source, did not include the purpose of disclosure. Client #5 was admitted on May 28, 2019 and was discharged on October 11, 2019. A consent to disclose information form, dated May 28, 2019, to an emergency contact and funding source did not include the purpose of disclosure. Client #7 was admitted on February 20, 2019 and was discharged on August 7, 2019. A consent to disclose information form, dated February 18, 2019, to an emergency contact, funding source and an unknown recipient did not include the purpose of disclosure. Client #8 was admitted on September 23, 2019 and was current at the time of inspection. A consent to disclose information form, dated September 23, 2019, to an emergency contact and funding source did not include the purpose of disclosure. Client #11 was admitted on June 13, 2019 and was discharged on September 13, 2019. A consent to disclose information form, dated June 12, 2019, to a funding source and an unknown recipient did not include the purpose of disclosure. Client #14 was admitted on August 19, 2019 and was current at the time of the inspection. A consent to disclose information form, dated June 12, 2019, to a funding source and an emergency contact did not include the purpose of disclosure. The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
All clinical and intake staff have been retrained on how to complete releases of information, and releases of information for emergency contacts. Staff were also informed that incomplete releases are not valid, and staff will receive corrective action plans if they are found. Charts will be reviewed by clinical supervisor in monthly random audits. |
709.34 (a) (2) 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:
(2) Selling or use of illicit drugs on the premises.
|
Observations
During a review of the unusual incident reports December 18-20, 2019, the project failed to report an unusual incident involving the selling or use of illicit drugs on the premises. The project failed to report an incident dated June 1, 2019 involving a client using illicit drugs in the bathroom to the department. The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
All staff have been retrained with our QCO on critical incident reporting, and all staff are now aware and trained that drug use requires a state report moving forward. The program director is responsible for submitting a report to the state after any incident report comes in for drug use or sales. |
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.
|
Observations
During a review of 18 patient records on December 18-20, 2019, the narcotic treatment program failed to 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.Patient # 8 was admitted on September 23, 2019 and was current at the time of inspection. Patient # 8 received 45 minutes of individual and 9 hours of group psychotherapy in November 2019. Patient #13 received 0 hours of individual and 10 hours of group in May 2019 and 30 minutes and 6 hours of group psychotherapy in June 2019. These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
All staff will be retrained on the requirements of psychotherapy per month, and will be held responsible with corrective action plans if they do not complete these hours or document why this was not possible. Retraining for staff will be completed February 21, 2020. |