INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on December 11, 2023, through December 12, 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, conducted on December 12, 2023, the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevents the penetration of insects and rodents.
The outside trash dumpster, located in the facility's parking lot, had lids that were open at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facilities staff will conduct daily rounds of the parking lot to ensure that the trash can lids are closed as required.
All staff will be reminded of this requirement via email by 1/12/24 and will also be reminded to report to management or facilities staff if they witness the trash can lid being open.
By 1/12/24, "Building Exterior/Trash Can closed" will be added to the weekly walkthrough Checklist. Walkthroughs will be completed by the Office Manager or other Facilities staff daily.
Any issue identified during the walkthrough that cannot be immediately resolved will be reported to the Program Director for further action.
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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 ensure each patient received 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 three of three applicable patient records reviewed.
Patient #1 was admitted February 27, 2023 and was active at the time of inspection. The record of service and progress notes indicated 30 minutes of psychotherapy during July 2023, 1 hour of psychotherapy during August 2023, 30 minutes of psychotherapy during September 2023, 0 minutes of psychotherapy during October 2023, and 30 minutes of psychotherapy during November 2023.
Patient #2 was admitted October 31, 2022 and was active at the time of inspection. The record of service and progress notes indicated 1 hour and 45 minutes of psychotherapy during October 2023 and 2 hours of psychotherapy during November 2023.
Patient #3 was admitted June 30, 2023 and was active at the time of inspection. The record of service and progress notes indicated 1 hour and 40 minutes of psychotherapy during October 2023 and 1 hour and 30 minutes of psychotherapy during November 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
By 1/12/24, The Program Director will review and provide a copy of regulation 715.19 to the clinical team to reference when scheduling counseling services.
The Program Director currently sends weekly updates regarding the client's counseling service attendance as it relates to financial requirements.
In addition to weekly updates, the Director will remind counselors that clients must be scheduled for counseling sessions in alignment with DDAP's regulation regarding the required amount of monthly service hours in relation to the client's duration in treatment.
The team will document canceled or missed appointments, which will indicate all attempts to schedule clients as required.
The Data Management Team will run reports that will be shared with the program management team. Reports will be run by the 15th and last day 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.
Reports will be reviewed in supervision with counselors to ensure awareness of client's monthly service levels.
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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