INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on December 4, 2023, through December 5, 2023 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's June 2022 through July 2023 training year in one of three applicable personnel records reviewed.Employee # 13 was hired as a counselor on October 19, 2021. The personnel record documented 5 hours of training received during the training year reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Following the completion of training attended by counselors, the Clinical Supervisor or Outpatient Director will log the training within the Learning Management System (LMS) in order to accurately track the training hours of each counselor. Current training hours and the annual training plan will be utilized and discussed during each month's individual supervision with each counselor. The Clinical Supervisor and Outpatient Director will also suggest upcoming trainings and schedule the counselor for the trainings when they are available in order to ensure that the counselor is attending the required minimum amount of training hours per fiscal year.
Clinical Supervisor informs new staff of all of their required trainings. Once a staff member completes a training it is sent to the Program Director and then added to a manual tracking spreadsheet that Program Director compares to the LMS Gap report. The Program Director will send out monthly updates to staff on what trainings are needed and their current hours for the fiscal year. This will be reviewed with staff during scheduled supervision that take place weekly and bi-weekly. This will be a standing agenda on our supervision template.
If for any reason program needs to file an exception, they will do so for reasons such as counselor being out on medical leave for most of the year therefore unable to meet the 25 hour requirement. Managers were educated on this process on 12/19/23 to support staff.
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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.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the FTE counselor caseload in outpatient programs did not exceed 35 active clients in three of fifteen applicable personnel records reviewed.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee #3 was hired as a clinical supervisor on December 20, 2021 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 16/40 = 0.4(FTE); 38/.4=95, which equals to a client/counselor FTE ratio of 95:1.Employee #4 was hired as a clinical supervisor on December 21, 2021 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 16/40 = 0.4(FTE); 48/.4=120, which equals to a client/counselor FTE ratio of 120:1.Employee #15 was hired as a clinical supervisor on February 12, 2018 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 16/40 = 0.4(FTE); 30/.4=75, which equals to a client/counselor FTE ratio of 75:1.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program will continue to interview to hire more clinical staff to ensure the FTE is within ratio and meets the requirements.
Since encountering this ratio with the counselors we have additional weekly meetings with our recruiting team to increase staffing efforts. We also have reworded our job descriptions to make it more appealing for potential candidates.
Census and caseload will be reviewed weekly to ensure counselors caseloads do not exceed 35 clients.
If or when program notices the FTE ratio is affected program will as for an exception due to being short staffed.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to complete an annual written individual staff performance evaluation, a copy of which shall be reviewed and signed by the employee, in one of four applicable personnel record reviewed. Employee #15 was hired as a clinical supervisor on February 12, 2018 and was still employed at the time of the inspection. There was no annual performance evaluation for the previous year documented in the personnel record as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward starting 12/12/2023, following completion of all staff performance evaluations, the original copy will be sent to each staff's HR file. A copy of the evaluation will be securely kept in the Program Director's office.
This was discussed during Managers meeting on December 12th and 19th as a friendly reminder.
Program Director will also update and send out a manual tracking sheet every month to all managers of when annual performance evaluations are due.
Upon any employee leaving we will ensure these are completed for anyone they supervise. We will provide the monthly notification, provide PD with a copy of the completed form for verification and to up date tracker. Lastly, if not received PD will then follow-up.
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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 narcotic treatment program failed to document that each patient was provided an average of 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotherapy, in two of two applicable patient records reviewed. Patient #1 was admitted March 3, 2023 and was active at the time of inspection. The record documented ninety minutes of psychotherapy during the month of September 2023 and sixty minutes of psychotherapy during the month of July 2023. Patient #3 was admitted July 29, 2022 and was active at the time of inspection. The record documented seven minutes of psychotherapy during the month of November 2023.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/6/23 Program Director shared and provided a copy of regulation 715.19 to the clinical team in order for them to reference these guidelines when scheduling.
Program Director sends weekly updates on services in relation to financial requirements, the Director will remind Clinical Supervisor to remind counselors that clients must continue to be scheduled for the appropriate regulatory hours they require. Regardless of whether a client also achieved the financial requirements.
The team will document canceled or missed appointments, which will indicate the attempts of scheduling clients accordingly.
The Data Management Team will run reports that will be shared with the program management team. Reports will be run by the 15th and 31st of each month. These reports will assist the program with the identification of clients who may not have met their required hours as regulated by state requirements. Any client identified as deficient through this reporting process, will be scheduled accordingly to ensure compliance by the month's end.
We are also creating a dashboard that will provide the total number of hours each month that will be accessible to all staff.
Reports will be reviewed in supervision with counselor's to ensure awareness of client's monthly service levels. Program Director will also review with Clinical Supervisors during supervision.
Treatment session attendance, in relation to the duration of program enrollment will be reviewed as part of the quarterly chart audit process to ensure compliance.
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