INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8-10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. The inspection was also conducted for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. 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.
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Plan of Correction
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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
Fourteen personnel records were reviewed for the licensing inspection conducted on January 8-10, 2019. The facility failed to ensure that all employees received a minimum of 6 hours HIV/AIDS and at least 4 hours of TB/STD training within the defined timeframe, using a Department-approved curriculum. This deficiency was found in employee records # 3, 15, and 16.
Employee # 3 was hired by the facility, as a counselor, on October 2, 2017. The employee was required to complete TB/STD training by no later than October 2, 2018. Documentation of this training was not found in the employee's record.
Employee # 15 was hired by the facility on January 3, 2017 and is employed as a business office clerk. The employee was required to complete HIV/AIDS training by no later than January 3, 2019. The facility failed to provide documentation of this training for this employee.
Employee # 16 was hired by the facility on January 9, 2009 and is employed as a business office supervisor. The employee was required to complete TB/STD training by no later than January 9, 2011. The facility failed to provide documentation of this training for this employee.
These findings were reviewed with the facility during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection, completed on December 20, 2017.
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Plan of Correction
All staff who were deficient have signed up for TB/STI training, and will be trained within 3 months (May 13, 2019). Staff will be trained at BHTEN for the current training needs, and internally when available moving forward.
The supervisor will ensure all staff is complaint with trainings in the future. All staff trainings will be tracked by the administrative assistant, as well as within our internal LMS system, and will be reviewed by the Program Director for compliance |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Fourteen personnel records were reviewed during the licensing renewal inspection conducted on January 8-10, 2019. The project failed to ensure that the project director completed at least 12 annual training hours, for the reviewed facility training year of July 1, 2017-June 30, 2018.
Employee # 1 was hired by the project on September 24, 2007 and began employment in the project director position on March 15, 2017. The employee required at least 12 annual training hours for the reviewed training year. Documentation in the employee's record indicated that 8.75 annual training hours were completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Director was informed of the unmet requirement for training hours, and he reported having already met training hours for the upcoming year.
The facility director will ensure that the project director maintains 12 hours of training annually, beginning 2/14/2019. The program director will be review from the Project Director's training hours during biweekly supervision until they are complete. The project director will identify trainings that are appropriate on his annual training plan. |
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
Six client records were reviewed on January 8-10, 2019, for the licensing renewal inspection. The facility failed to obtain a valid informed and voluntary consent to release information. In addition, the facility failed to ensure that that a consent to release information did not exceed the limitations imposed in 4 Pa. Code 255.5 (b).
Client # 1 was admitted into treatment on June 18, 2015 and was still active in treatment. A consent to release information to Medical Assistance, signed by the client on August 31, 2018, authorized the release of the clients "entire record".
Client # 2 was admitted into treatment on April 13, 2018 and was discharged on December 5, 2018. Consent to release information forms documented in the client's record, for the following agencies/companies, only authorized the facility to obtain information from the agencies:
-A managed care agency
othe associated consent form was signed by the client on April 9, 2018.
-A diagnostic laboratory
othe associated consent form was signed by the client on April 9, 2018.
Client # 3 was admitted into treatment on September 21, 2018 and was still active in treatment. Consent to release information forms documented in the client's record, for the following agencies/companies, only authorized the facility to obtain information from the agencies:
-A managed care agency
othe associated consent form was signed by the client on September 21, 2018.
-A diagnostic laboratory
othe associated consent form was signed by the client on September 21, 2018.
Client # 4 was admitted into treatment on October 20, 2010 and was still active in treatment. On consent to release information forms documented in the client's record, the facility failed to appropriately identify the name of the agency or organization to whom disclosure was to be made. A consent to release information to an "emergency contact", signed by the client on October 20, 2018, did not specify the name of the emergency contact. In addition, a consent to release information to a "criminal justice system", signed by the client on October 20, 2018, did not specify the agency or representative.
Client # 5 was admitted into treatment on July 27, 2017 and was discharged on June 20, 2018. Consent to release information forms documented in the client's record, for the following agencies/companies, only authorized the facility to obtain information from the agencies:
-A managed care agency
othe associated consent form was signed by the client on July 27, 2017.
-A diagnostic laboratory
othe associated consent form was signed by the client on July 27, 2017.
Client # 6 was admitted into treatment on May 7, 2010 and was still active in treatment. A valid consent to release information to a managed care agency, the client's treatment funding source, was not documented in the client's record. In addition, the facility failed to document a valid consent to release information to a pharmacy receiving the client's Buprenorphine prescription information from the facility.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was cited for non-compliance of this standard during the previous licensing renewal inspection, completed on December 20, 2017.
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Plan of Correction
The forms for consent to release information will now be labeled correctly, where the release to and release from will both be labeled with the party who is obtaining information.
Staff will be retrained by 2/28/2019 on how to complete Consent to release information by the program director, and this training will include identifying specifically what information is able to be released (not entire chart).The clinical supervisor will review the consents moving forward during chart audits monthly. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Six client records were reviewed for the licensing renewal inspection, conducted on January 8-10, 2019. For client record # 2, the facility failed to document that the client received written notification of the facility's decision to involuntarily terminate the client's treatment.
Client # 2 was admitted into treatment on April 13, 2018 and was discharged on December 5, 2018.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All clients who are involuntarily discharged will receive a letter of termination and this will be filed in the chart upon discharge beginning immediately.
The Program Director will review all involuntary terminations to ensure a written letter is documented in the chart within 30 days of the client's termination. This policy will be instituted immediately. |
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.
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Observations
The project failed to develop and implement policies and procedures to respond to the selling or use of illicit drugs on the premises.
The project's Incident Management and Critical Event Reporting policy fails to address the selling or use of illicit drugs on the premises.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Incident Management and Critical event policy has been updated to address drug sales on premises and is now part of our required incident reporting.
The clinical supervisor will follow up with addressing any suspected drug sales, and ensure that an incident report is completed.
All staff will be informed of the policy addition at the next all staff meeting on 2/22/2019, and will be informed and trained by the program director |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility's administrative records were reviewed during the licensing renewal inspection conducted on January 8-10, 2019. Based on a review of the facility's incident reporting documentation, the facility failed to report to the Department events at the facility that required the presence of police and ambulance personnel. These events occurred on the following dates: June 20, 2018, July 18, 2018, September 27, 2018 and December 1, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All calls of 911 or emergency will now have an incident report sent to the state following incident.
Previously, incident reports were done for all 911 calls, but only internal reports were completed. The program director will be responsible for sending an external report to the state for all incident reports that have an emergency call to 911 for police, fire, or ambulance, and this will be reviewed at the monthly Parkside Incident Review call. All reports will be completed and submitted within 3 days. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Six client records were reviewed for the licensing renewal inspection, conducted on January 8-10, 2019. For client record # 4, the facility failed to maintain documentation that the female patient had been fully informed of the possible risk to an unborn child from continued use of illicit drugs and from use of, or withdrawal from, a narcotic drug administered in treatment.
Client # 4, a female patient, was admitted into treatment on October 20, 2010 and was still active in treatment. Documentation of informed patient consent was not found in the client's record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Female patients will be informed of possible risks to unborn children at intake with intake coordinator, and this will be documented. A monthly chart audit is completed by the counselor, and this form will be identified in these monthly audits to ensure completion. The clinical supervisor will review the chart audits to ensure this documentation is included for all female patients.
The intake coordinator will be trained by the program director to review the information verbally and provide the information to ensure all female clients are informed, starting on 3/1/2019.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Six client records were reviewed for the licensing renewal inspection, conducted on January 8-10, 2019. For client record # 4, the facility failed to maintain documentation of an informed, voluntary, written consent for the administration of a narcotic agent for maintenance treatment.
Client # 4, a female patient, was admitted into treatment on October 20, 2010 and was still active in treatment. Documentation of informed patient consent was not found in the client's record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Informed consent documentation will be completed at intake for all clients who receive treatment. Form will be checked during clinical supervision with staff. |
715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
A take-home bottle label was reviewed for compliance on January 9, 2019. The facility failed to ensure that take-home bottle labels noted the facility's telephone number.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Take home medication bottle labels have been changed since the inspection and now have all required information, including the facility phone number. |
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
Six client records were reviewed for the licensing renewal inspection, conducted on January 8-10, 2019. For client records # 2 and 3, the facility failed to ensure that monthly psychotherapy hours provided to the client included at least one hour of individual psychotherapy.
Client # 2 was admitted into treatment on April 13, 2018 and was discharged on December 5, 2018. The client received less than one hour of individual psychotherapy for the following months: May 2018, June 2018, August 2018, September 2018, and October 2018.
Client # 3 was admitted into treatment on September 21, 2018 and was still active in treatment. The client received less than one hour of individual psychotherapy for the following months: October 2018, November 2018, and December 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff have been informed that clients are required to attend a minimum of 1 hour of individual therapy monthly, and missed sessions will be documented. Staff who do not document 1 hour of treatment or interventions on how to improve treatment adherence will receive a corrective action plan.
Charts will be checked in clinical supervision with clinical supervisor, as well as our monthly random chart audits. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Five client records were reviewed for the outpatient maintenance activity, for the licensing renewal inspection conducted on January 8-10, 2019. As a referring narcotic treatment program, the facility failed to document the transfer of all required patient files to a receiving narcotic treatment program, for client record # 5.
Client # 5 was admitted into treatment on July 27, 2017 and was discharged on June 20, 2018, upon transferring to another narcotic treatment program. The client's record did not contain documentation verifying the transfer of any of the required patient files.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All clients who transfer will now include a copy of the sent transfer packet in their chart following transfer. Client #5 was transferred to our other clinic, 5000 Parkside, thus a copy of the packet was not included in the chart. Moving forward, all transfers, internally and externally, will have a copy made of any documentation by the counselor and added to the chart. This will be checked in clinical supervision and monthly audits to ensure compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Five client records were reviewed for the outpatient maintenance activity, for the licensing renewal inspection conducted on January 8-10, 2019. The facility failed to document a timely annual evaluation for client records # 1 and 4.
Client # 1 was admitted into treatment on June 18, 2015 and was still active in treatment. The most recent annual evaluation documented in the client's record was completed on August 31, 2018 and was due to be completed by no later than June 2018.
Client # 4 was admitted into treatment on October 20, 2017 and was still active in treatment. The most recent annual evaluation documented in the client's record was completed on January 7, 2019 and was due to be completed by no later than October 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Client charts are reviewed monthly by other clinical staff and charts with noted deficiencies, such as a late annual evaluation, will be addressed in clinical supervision by the clinical supervisor. The clinical supervisor assigns chart reviews to counselors (to ensure that counselors do not review their own chart) each month.
Counselors who have charts consistently with missing or late annual evaulations will receive a corrective action plan by the clinical supervisor. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Six client records were reviewed for the licensing renewal inspection, conducted on January 8-10, 2019. The facility failed to document a complete personal history during the intake process for client records # 2.
Client # 2 was admitted into treatment on April 13, 2018 and was discharged on December 5, 2018. A Biopsychosocial assessment was not documented in the client's record. This assessment would have included the client's personal history.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All clients will receive personal history, included within the biopsychosocial evaluation, within 60 days of admission and be completed in an in-person interview by the counselor. Monthly audits conducted by the counselors will check charts to ensure this is complete. The clinical supervisor will assign counselors charts to check to ensure counselors are not checking their own chart. If a biopsychosocial assessment is not complete, counseling staff responsible will receive a corrective action plan. Any late personal history interviews will be reported to the program director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Six client records were reviewed for the licensing renewal inspection, conducted on January 8-10, 2019. The facility failed to document a psychosocial evaluation for client record # 2.
Client # 2 was admitted into treatment on April 13, 2018 and was discharged on December 5, 2018.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All clients will receive a psychosocial evaluation within 60 days of admission. If a psychosocial evaluation is not complete, counseling staff responsible will receive a corrective action plan.
Charts are audited monthly by counseling staff and results are reviewed by clinical supervisor and director. Information is then reviewed in Merakey quarterly PQI meetings. |