INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 9, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on interviews with patients and staff, the facility failed to ensure privacy so that counseling cannot be seen or heard outside the counseling room.
The findings include:
A complaint investigation took place on May 9, 2011. During the investigation, staff and patients disclosed that group counseling sessions at times will have the counseling doors open due to temperature issues. Leaving the counseling doors open does not ensure the patient's privacy since any patient or staff member can walk past the counseling offices and overhear and/or view the counseling sessions at any given time.
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Plan of Correction
The Management Staff will ensure that the counseling office doors are closed while providing clinical services.
The counseling staff will be notified of maintaining patient's privacy by keeping the door closed while providing clinical services in supervision and staff meeting by program management.
Repairs to the air conditioning system will be monitored on the ongoing basis with our facilities personnel.
Additionally, a letter requesting the opportunity to utilize available first floor group rooms was sent to BDAP on May 12th, 2011. The use of this space will allow for larger group rooms, private hallways to further ensure a confidential and comfortable environment. The same monitoring process as currently communicated with staff would continue should this request be approved.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on interviews with patients and staff, the facility failed to comply with the Department of Public Welfare Medical Assistance Manual requirements relative to the number of participants in group counseling sessions.
The findings include:
A complaint investigation took place on May 9, 2011. During the investigation, staff and patients disclosed that the group counseling sessions included between 10 and 25 patients, depending on the counselor and the type of group. If one patient in a group counseling session is funded through the Office of Medical Assistance, the facility must comply with the Department of Public Welfare's Medical Assistance Manual requirement that group treatment sessions be limited to 10 patients. The facility failed to limit group counseling sessions to 10 patients.
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Plan of Correction
We clearly acknowledge that psycho-therapy groups which include medical assistance reimbursed patients must be capped at 10 patients per group. The Project Director will continue monitor group size and train staff in supervision and team meetings to ensure that the psycho-therapy groups will remain capped at 10 patients per group. Additionally, the psycho-therapy and education groups will be clearly differentiated and labeled on posted group schedules for staff and patients. This will also be captured on each patient's individualized treatment plan. |