INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Delaware County 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 and the Staffing Requirements Facility Summary Report, the facility failed to ensure each counselor completed at least 25 clock hours of training annually in one of four applicable personnel records reviewed.Employee #4 was hired as a counselor on November 19, 2018. The personnel record included documentation that 7 hours and 45 minutes of training hours were completed during the facility's July 1, 2023 through June 30, 2024 training year.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 Program Director (PD) will ensure staff log the training within the Learning Management System (LMS).
Program Director will create an excel spreadsheet by 12/01/2024 to track all internal and external training, to ensure the appropriate hours are completed both internally & externally.
LMS will also be checked monthly by the Program Director for internal training and the counselors will provide certificates from external training to the PD. Training plans and needs will be reviewed with each staff member during monthly supervision. The PD will also review upcoming training opportunities from LMS, the DDAP TMS, and the county, to ensure that all staff are attending required minimum training hours per training year during monthly supervisions or during LPQI meetings
All staff will be trained and educated on this process by/before December 1, 2024.
Prior to the end of the Fiscal Year, a calendar reminder will be scheduled in May to review all hours on the training tracker to identify staff that still need to complete the 25 hours prior to July 31, 2025, and assign training accordingly.
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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 include in the personnel record an annual written individual staff performance evaluation, which shall be reviewed and signed by the employee, in four of five personnel records reviewed. Employee #2 was hired as a counselor on June 1, 2015. At the time of the inspection, there was no written performance evaluation, for the previous year, documented in the personnel record.Employee #3 was hired as a counselor on October 10, 2005. At the time of the inspection, there was no written performance evaluation, for the previous year, documented in the personnel record.Employee #4 was hired as a counselor on November 19, 2018. At the time of the inspection, there was no written performance evaluation, for the previous year, documented in the personnel record.Employee #5 was hired as a counselor on September 24, 2012. At the time of the inspection, there was no written performance evaluation, for the previous year, documented in the personnel record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The former PD did not send the 2024 evals to HRO-Records, to be placed in their personnel file, prior to her leaving.
The Executive Director (ED) will complete another 2024 evaluation with all counselors, with the new Program Director. This will be placed in their HR file/personnel record, by emailing a copy to HRO-Records@merakey.org.
Each year, all staff evaluations will be completed by the Program Director by/before December of each year, and copies will be sent to HRO-Records, with the Executive Director copied on the email. A calendar reminder has been added for December 2025 to complete annually by the PD. The ED will review with the PD at the time of their eval to ensure completion for all counselors/program staff and ensure completion for the entire project.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of seven client records reviewed. Client # 2 was admitted on January 31, 2024 and was active at the time of inspection. A treatment plan update was completed on February 28, 2024 and the next update was due no later than April 28, 2024; however, the update was not completed until May 6, 2024. Additionally, a treatment plan update was completed on June 5, 2024 and the next update was due no later than August 5, 2024; however, the update was not completed until September 4, 2024.Client # 3 was admitted on March 14, 2024 and was active at the time of inspection. A treatment plan update was completed on July 29, 2024 and the next update was due no later than September 29, 2024; however, the update was not completed at the time of inspection.Client # 4 was admitted on February 9, 2024 and was discharged on May 7, 2024. The comprehensive treatment plan was completed on February 9, 2024 and the first update was due no later than April 9, 2024; however, the update was not completed prior to the client's discharge. Client # 5 was admitted on January 4, 2024 and was discharged on May 7, 2024. A treatment plan update was completed on February 28, 2024 and the next update was due no later than April 28, 2024; however, the update was not completed prior to the client's discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will create an excel spreadsheet by 12/01/2024 to track all treatment plan due dates. All plan dates will be updated every 60 days as applicable and will be reviewed with each staff member during monthly supervision, to ensure timely completion. The Program Director will review the tracker and the "treatment plans due to expire" report weekly, and then send email reminders to staff of due dates prior to expiration. The organization is also working with the electronic health record on notifications to alert staff when plans are coming up due.
Beginning 12/1/24, to monitor compliance, five charts will be audited monthly by the Program Director. Any issues identified will be reported to the Executive Director for management.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in two of three applicable client records reviewed.Client #2 was admitted on January 31, 2024 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.Client #3 was admitted on March 14, 2024 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 and Client #3 will have a case conference completed by 11/22/2024.
The Program Director will create an excel spreadsheet by 12/01/2024 to track all case consultation due dates. All consultation note dates will be updated every month, as applicable and will be reviewed with each staff member during monthly supervision, to ensure timely completion. The organization is also working with the electronic health record on notifications to alert staff when consultation notes are coming due.
Review of consultation note completion will be added to the LPQI agenda or MOR agenda to discuss barriers and completion by 12/01/2024
Beginning 12/1/24, to monitor compliance, five charts will be audited monthly by the Program Director. Any issues identified will be reported to the Executive Director for management.
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