INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on November 8, 2021 through November 9, 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 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors, who have not functioned for 2 years as supervisors in the provision of clinical services, completed a core curriculum in clinical supervision in two of three applicable personnel records reviewed.Employee # 4 was hired as a clinical supervisor on July 19, 2021. There was no documentation of clinical supervision experience prior to being hired and no documentation that the clinical supervision core curriculum training was completed as of the date of the inspection.
Employee # 5 was hired as a clinical supervisor on February 1, 2021. There was no documentation of clinical supervision experience prior to being hired and no documentation that the clinical supervision core curriculum training was completed 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
The Facility Director checks the DDAP TMS on a weekly basis for the clinical supervisor core curriculum training. The Facility Director will also look for alternative trainings and seek approval from DDAP. Facility Director most recently reached out to DDAP for an approval on November 9, 2021; no approval has been received yet for this training. |
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 a review of the facility's Staffing Requirement Facility Summary Report and employee training files, the facility failed to ensure that all staff persons completed the mandatory 4 hours of TB/STD and other health related topics training within the regulatory time frame in one of eighteen personnel records reviewed.
Employee # 8 was hired as a counselor on September 1, 2020. The TB/STD training was due to be completed no later than September 1, 2021. However, the training was not completed until October 27, 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project has transitioned to a Learning Management System (LMS) to track staffs' required trainings in October 2021. LMS will generate reports monthly that the Facility Director will review for compliance. The Facility Director will check weekly for available trainings and send training information to staff who need to complete these required trainings. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain all bathrooms in a functional, clean and sanitary manner.
The client bathrooms, in the client waiting room, had graffiti on the walls, doors and mirrors. Also, there was a piece of paper, with what appeared to be blood, on the floor beside the toilet. Additionally, there was a ceiling tile missing from the corner of the ceiling above the toilet.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reached out to facilities on November 10, 2021, to request the ceiling tile be replaced and for the graffiti to be addressed. The Facility Director also requested that the porters continue to check and clean the bathrooms every thirty minutes and advise of any issues that need to be addressed. Front Desk staff will visit the bathrooms at least once an hour for additional monitoring. Any reported issues will be sent to facilities by end of business that day. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of eight client records reviewed.
Client #6 was admitted on October 11, 2011 and was active at the time of inspection. There was a release of information form to the funding source, signed and dated by the client April 3, 2019, with an expiration date of April 3, 2020. There was no current consent to release information form signed by the client after the expiration of the previous form and there was evidence of billing after that date.
The findings were discussed with facility staff during the licensing process
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Plan of Correction
The Project met with the QCO department on November 17, 2021, to review the Project's consents and process and timeline for updating consents. Discussions will continue to determine if the Project should have consents expire at a condition or event instead of on an annual basis. The Project has read DDAP regulation regarding expiration dates and reached out to their SCA's compliance department on November 11, 2021, to discuss their regulations. Counselors utilize a tracking spreadsheet to monitor due dates. Tracker is reviewed during supervisions to ensure ROI's are completed in a timely manner. The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations and have not expired. A selection of Intake charts will also be audited upon completion of Intake. Staff will use tools provided by the Project to update consents with an expiration date before the expiration date occurs. |
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 a review of client records, the facility failed to identify the specific information to be disclosed on releases of information in two of eight client records reviewed.
Client #5 was admitted on May 20, 2021 and was active at the time of inspection. There was a consent to release information form to "Merakey Physicians" that failed to document the specific information to be disclosed.
Client #6 was admitted on October 11, 2011 and was active at the time of inspection. There was a consent to release information form to a funding source that failed to document the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project met with the QCO department on November 17, 2021, to review the Project's consents and process and timeline for updating consents. Discussions will continue to determine if the Project should have consents expire at a condition or event instead of on an annual basis. The Project has read DDAP regulation regarding expiration dates and reached out to their SCA's compliance department on November 11, 2021, to discuss their regulations. Counselors utilize a tracking spreadsheet to monitor due dates. Tracker is reviewed during supervisions to ensure ROI's are completed in a timely manner. The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations to include, specifying what information should be disclosed. A selection of Intake charts will also be audited upon completion of Intake. The Project will retrain staff on how to accurately complete consents by December 31, 2021 |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain the dated signature of the client on consent to release information forms in two of eight client records reviewed.
Client #4 was admitted January 10, 2017 and was discharged October 25, 2021. There was a consent form to a laboratory service; however, the form failed to document the dated signature of the client.
Client #5 was admitted on May 20, 2021 and was active at the time of inspection. There was a consent to release information form to "Merakey Physicians"; however, the form failed to document the dated signature of the client.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The Project met with the QCO department on November 17, 2021, to review the Project's consents and process and timeline for updating consents. Discussions will continue to determine if the Project should have consents expire at a condition or event instead of on an annual basis. The Project has read DDAP regulation regarding expiration dates and reached out to their SCA's compliance department on November 11, 2021, to discuss their regulations. Counselors utilize a tracking spreadsheet to monitor due dates. Tracker is reviewed during supervisions to ensure ROI's are completed in a timely manner. The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations to include, the date client signed. A selection of Intake charts will also be audited upon completion of Intake. The Project will retrain staff on how to accurately complete consents by December 31, 2021
In review of chart #5, this consent was never meant to be a part of the chart. It was in a separate folder with information sheets for the client. The consent in question, which the client started, happened to be in there. The Project will ensure that paper files do not contain information not meant for the official record.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to obtain a dated signature of a witness on consent to release information forms in one of eight records reviewed.
Client #5 was admitted on May 20, 2021 and was active at the time of inspection. There was a consent to release information form to "Merakey Physicians"; however, the form failed to document the dated signature of a witness.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The Project met with the QCO department on November 17, 2021, to review the Project's consents and process and timeline for updating consents. Discussions will continue to determine if the Project should have consents expire at a condition or event instead of on an annual basis. The Project has read DDAP regulation regarding expiration dates and reached out to their SCA's compliance department on November 11, 2021, to discuss their regulations. Counselors utilize a tracking spreadsheet to monitor due dates. Tracker is reviewed during supervisions to ensure ROI's are completed in a timely manner. The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations to include, the date witness signed. A selection of Intake charts will also be audited upon completion of Intake. The Project will retrain staff on how to accurately complete consents by December 31, 2021
In review of chart #5, this consent was never meant to be a part of the chart. It was in a separate folder with information sheets for the client. The consent in question, which the client started, happened to be in there. The Project will ensure that paper files do not contain information not meant for the official record.
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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 a review of client records the facility failed to document the date, event or condition upon which a consent to release information form will expire in one of eight client records reviewed.
Client #5 was admitted on May 20, 2021 and was active at the time of inspection. There was a consent to release information form to "Merakey Physicians"; however, the form failed to document a date, event, or condition upon which the consent would expire.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project met with the QCO department on November 17, 2021, to review the Project's consents and process and timeline for updating consents. Discussions will continue to determine if the Project should have consents expire at a condition or event instead of on an annual basis. The Project has read DDAP regulation regarding expiration dates and reached out to their SCA's compliance department on November 11, 2021, to discuss their regulations. Counselors utilize a tracking spreadsheet to monitor due dates. Tracker is reviewed during supervisions to ensure ROI's are completed in a timely manner. The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations to include, the date, event, or condition upon which consent expires. A selection of Intake charts will also be audited upon completion of Intake. The Project will retrain staff on how to accurately complete consents by December 31, 2021
In review of chart #5, this consent was never meant to be a part of the chart. It was in a separate folder with information sheets for the client. The consent in question, which the client started, happened to be in there. The Project will ensure that paper files do not contain information not meant for the official record.
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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 a review of client records, the facility failed to ensure that a copy of all informed and voluntary consent to release information forms were offered to the client in two of eight client records reviewed.
Client #4 was admitted January 10, 2017 and was discharged October 25, 2021. There was a release of information form, signed and dated by the client on March 3, 2020, however, there was no documentation in the record that a copy of the form was offered to the client.
Client #6 was admitted on October 11, 2011 and was active at the time of inspection. There was a release of information form in the client record; however, there was no documentation in the record that a copy of the form was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project met with the QCO department on November 17, 2021, to review the Project's consents and process and timeline for updating consents. Discussions will continue to determine if the Project should have consents expire at a condition or event instead of on an annual basis. The Project has read DDAP regulation regarding expiration dates and reached out to their SCA's compliance department on November 11, 2021, to discuss their regulations. Counselors utilize a tracking spreadsheet to monitor due dates. Tracker is reviewed during supervisions to ensure ROI's are completed in a timely manner. The Project will continue monthly audits for monitoring consents to ensure consents are being completed following regulations to include, whether the client was offered a copy of consent. A selection of Intake charts will also be audited upon completion of Intake. The Project will retrain staff on how to accurately complete consents by December 31, 2021 |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed document a random urinalysis at least monthly in one of five applicable patient records reviewed.
Client #4 was admitted January 10, 2017 and was discharged October 25, 2021. There was no documentation in the record that a random urinalysis was conducted during the month of October 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Project will conduct monthly chart audits to ensure they are complying with regulatory standards and documenting when clients are in placement as facilities such as, but not limited to detox, rehab, medical hospitalizations, and incarceration. If an individual is in placement and unable to come to program for a monthly UDS, program will work with placement facility to obtain a UDS sample from them or obtain UDS results. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 facility failed to document that each patient, who has been in treatment for three and four years, received at least 1 hour of psychotherapy group or individual sessions per month in one of five applicable patient records reviewed.
Client #4 was admitted January 10, 2017 and was discharged October 25, 2021. The record documented 0 (zero) psychotherapy hours for the month of October 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Designated staff will conduct monthly chart audits to ensure they are complying with regulatory standards and documenting when clients are in placement as facilities such as, but not limited to detox, rehab, medical hospitalizations, and incarceration. Audit results will be reviewed by clinical supervisors and counselors who are not meeting with clients per DDAP regulations will receive supervision around this topic. |