D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.

MERAKEY COLMAR
2506 N. BROAD ST. SUITE 201 & 202
COLMAR, PA 18915

Inspection Results Overview Definitions Surveys Additional Services Search

Survey conducted on 10/29/2020

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on October 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Merakey 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:	Plan of Correction
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.
Observations Based on a review of the Project Director/Facility Director personnel records, the facility failed to provide documentation of at least 12 clock hours of required training annually.Employee # 1 was hired as the project director/facility director on August 10, 2015. There was no documentation of 12 hours of trainings documented in the personnel record for the training year June 30, 2019 to July 1, 2020.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction Clinical Supervisor will meet with Merakey's Training Department to develop a report for tracking annual training hours for all staff by January 15, 2021. Clinic Director & Clinical Supervisor will review reports during regularly scheduled supervisions, at minimum, twice a year. If staff are to be found deficient in any training requirements, The Clinic Director and Clinical Supervisor will set a deadline for completion of deficient training items. Review of deficient items will be reviewed at staff's next supervision to ensure compliance in this area.
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.
Observations Based on the review of staff personnel records, the facility failed to provide documentation of at least 25 hours of the required annual training for employees # 5 and # 6.Employee # 5 was hired as a counselor on June 10, 2013. There was no documentation of 25 hours of trainings documented in the personnel record for the training year June 30, 2019 to July 1, 2020.Employee # 6 was hired as a counselor on July 23, 2018. There was no documentation of 25 hours of trainings documented in the personnel record for the training year June 30, 2019 to July 1, 2020.These findings were reviewed with facility staff during the licensing process.	Plan of Correction Employees 5 & 6 did both complete 25 hours of training however the information is still being gathered and will be uploaded into our Learning Management System by 12/14/20. Moving forward, Clinical Supervisor will meet with Merakey's Training Department to develop a report for tracking annual training hours by January 15, 2021. Reports will be reviewed during supervision, at minimum, twice a year. External training certificates will be uploaded into our Learning Management System.
704.12(a)(6) LICENSURE OutPatient Caseload 704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios. (a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client. (6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
Observations Based on a review of the Staffing Requirements Facility Summary Report, the FTE counselor caseload for four counselors in the outpatient program exceeded 35 active clients. Also, the overall facility client to counselor FTE exceeded 35/1.Counselor total hours = 4949/37.5=1.3066Client total = 4949/1.3066=37.5019 = 38/1Employee # 3 was hired as a counselor on June 15, 2020 and was still in this position at the time of the inspection. Employee # 3 was reported to have 9 hours per week devoted to their 9 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 9/37.5 = .24(FTE); 9/.24 = 37.5, which equals to a client/counselor ratio of 38:1.Employee # 4 was hired as a counselor on December 1, 2020 and was still in this position at the time of the inspection. Employee # 4 was reported to have 11 hours per week devoted to their 11 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 11/37.5 = .2933(FTE); 11/.2933 = 37.5042, which equals to a client/counselor ratio of 38:1.Employee # 5 was hired as a counselor on June 10, 2013 and was still in this position at the time of the inspection. Employee # 5 was reported to have 19 hours per week devoted to their 19 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 19/37.5 = 0.5066(FTE); 19/0.5066 = 37.5049, which equals to a client/counselor ratio of 38:1.Employee # 6 was hired as a counselor on July 23, 2018 and was still in this position at the time of the inspection. Employee # 6 was reported to have 10 hours per week devoted to their 10 clients on their caseload.The FTE counselor ' s caseload calculation is as follows: 10/37.5 = .2666(FTE); 10/.2666= 37.5093, which equals to a client/counselor ratio of 38:1.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 37.5. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.These findings were reviewed with facility staff during the licensing process.	Plan of Correction Clinical Supervisor reviewed submitted information provided on the Facility Staffing Summary Report and identified a calculation error which has been corrected for Employees #4 and #5 that now meet counselor/client ratios. Moving forward, ratios will be monitored by Clinical Supervisor during monthly Supervision to determine active vs. inactive clients. Clients that are inactive for 14 days will be discharged. If calculations will exceed maximum client/counselor ratio: Cases will be transferred to another counselor or Clinical Supervisor will discuss with Clinic Director the need to consider hiring additional counselors to comply with regulatory counselor/staff ratios.
705.28 (d) (1) LICENSURE Fire safety. 705.28. Fire safety. (d) Fire drills. The nonresidential facility shall: (1) Conduct unannounced fire drills at least once a month.
Observations Based on the facility fire drill log, the facility failed to provide documentation of an unannounced fire drill conducted at least once a month. There was no documentation of a fire drill occurring the months of December 2019, January, May, and June 2020.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction We are creating a recurring Outlook "to-do" reminder monthly on the 1st of each month for the Office Manager and Facility Director to ensure that there is adequate time and awareness that a fire drill will be completed. There will also be an alert on the Outlook Calendar at the last week of each month to reinforce the completion of the unannounced fire drill. It will be the responsibility of the Office Manager to complete the fire drills and enter them into the Fire Drill Log. Updated reminders will begin in December 2020. Director of Quality Management will review Fire Drill Log on a quarterly basis to ensure consistent completion of Fire Drills.
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.
Observations Based on the review of six personnel records, the facility failed to provide documentation of an annual written individual staff performance evaluation that was reviewed and signed by the employee in employee # 2's personnel record. Employee # 2 was hired on November 3, 2008 and promoted to clinical supervisor on February 1, 2020. There was no documentation of an annual evaluation to have been completed by November 3, 2019.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction An annual evaluation was conducted and completed on 11/25/20 for Employee #2. In order to ensure this deficiency will not recur, effective immediately, the Clinic Director has directed all Managers & Supervisors to schedule annual performance evaluations for all staff for June 2021 and each June thereafter. An Outlook reminder will be utilized to remind the Clinic Director of this expectation and to guarantee its completion. All Staff will remain on this schedule moving forward.
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.
Observations Based on one of five client records reviewed, the facility failed to update an expired informed and voluntary consent form prior to releasing information. Client # 1 was admitted on July 19, 2019 and was still active at the time of the inspection. An informed and voluntary consent to release form to a lab expired on July 18, 2020. A request to a lab was conducted on August 6, 2020.These findings were reviewed with facility staff during the licensing process.	Plan of Correction Expired release was updated on 10/20/2020. All Staff will be re-trained on Release of Information completion by December 9,2020. Attendance will be captured on Supervision log to ensure all staff are in attendance. Releases will be tracked by therapists and updated annually on tracking form attached. This matter will be referred to the Quality Compliance Division of QCO for investigation and follow up, which may include restitution for any identified overpayment.
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.
Observations Based on a review of one of five client records reviewed, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 3.Client # 3 was admitted on March 4, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record to a funding source dated March 4, 2020 allowed for the release of the "entire record".These findings were reviewed with project and facility staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction To correct this deficiency the plan is to re-train All Staff on proper Release of Information completion by December 9,2020 and ensure that information to be released must be specific in nature. Attendance will be captured on Supervision log to ensure all staff are in attendance. Releases will be tracked by therapists and updated annually on a newly created tracking form to monitor compliance with this corrective action. This matter will be referred to the Quality Compliance Division of QCO for investigation and follow up, which may include restitution for any identified overpayment.
709.30 LICENSURE Client Rights § 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
Observations Based on two of five client records reviewed, the facility failed to provide documentation of acknowledgement by the clients that they have been notified of their rights in client records # 4 and # 5.Client # 4 was admitted on June 23, 2020 and was discharged on October 20, 2020. The clients rights form in the client record did not document written acknowledgement of the client being notified their rights. Client # 5 was admitted on March 30, 2020 and was still active at the time of the inspection. There was not documentation of the client being notified of their rights in the client record. These findings were reviewed with project and facility staff during the licensing process.	Plan of Correction Our D&A Intake Packet will be updated to include a cover sheet to include a verbal telehealth acknowledgement section by January 15, 2021. A copy of the Client Rights and Responsibilities will be sent to all clients via method of their choice (email or postal mail). Method and date sent will be documented in a corresponding progress note. Intake Coordinator will review all intake paperwork to ensure completeness. This matter will be referred to the Quality Compliance Division of QCO for investigation and follow up, which may include restitution for any identified overpayment.
709.30 (2) LICENSURE Client rights § 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Observations Based on four of five client records reviewed, the facility failed to provide documentation of written acknowledgement that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. The client rights provided to the client were missing the verbiage of "ethnicity and marital status".These findings were reviewed with project and facility staff during the licensing process.	Plan of Correction Our D&A Intake Packet will be updated and The Clients Rights document regarding non-discrimination will include "ethnicity and marital status". All current clients will have Client Rights and Responsibilities regarding non-discrimination updated by January 15, 2021. Process will begin for all new client intakes by December 14,2020.
709.30 (3) LICENSURE Client rights 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Observations Based on four of five client records reviewed, the facility failed to provide documentation of written acknowledgement that clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. Reasons for removing sections shall be documented in the record was missing from the client rights acknowledgement form. These findings were reviewed with project and facility staff during the licensing process.	Plan of Correction Clients Rights and Responsibilities will be revised to include required language and added to Intake packet by January 15, 2021. All current clients will have Client Rights and Responsibilities updated by January 15, 2021. Process will begin for all new client intakes by December 14, 2020. Clinical Supervisor will review Merakey's Consumer Rights Policy 709.30 during December's D&A group supervision meeting.
709.30 (4) LICENSURE Client rights § 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (4) Clients have the right to appeal a decision limiting access to their records to the director.
Observations Based on four of five client records reviewed, the facility failed to provide documentation of written acknowledgement that clients have the right to appeal a decision limiting access to their records to the director. These findings were reviewed with project and facility staff during the licensing process.	Plan of Correction Clients Rights and Responsibilities will be revised to include required language and added to Intake packet by January 15, 2021. All current clients will have Client Rights and Responsibilities updated by January 15, 2021. Process will begin for all new client intakes by December 14, 2020. Clinical Supervisor will review Merakey's Consumer Rights Policy 709.30 during December's D&A group supervision meeting
709.30 (5) LICENSURE Client rights § 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Observations Based on four of five client records reviewed, the facility failed to provide documentation of written acknowledgement that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These findings were reviewed with project and facility staff during the licensing process.	Plan of Correction Clients Rights and Responsibilities will be revised to include required language and added to Intake packet by January 15, 2021. All current clients will have Client Rights and Responsibilities updated by January 15, 2021. Process will begin for all new client intakes by December, 14, 2020. Clinical Supervisor will review Merakey's Consumer Rights Policy 709.30 during December's D&A group supervision meeting
709.30 (6) LICENSURE Client rights § 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (6) Clients have the right to submit rebuttal data or memoranda to their own records.
Observations Based on four of five client records reviewed, the facility failed to provide documentation of written acknowledgement that clients have the right to submit rebuttal data or memoranda to their own records.These findings were reviewed with project and facility staff during the licensing process.	Plan of Correction Clients Rights and Responsibilities will be revised to include required language and added to Intake packet by January 15, 2021. All current clients will have Client Rights and Responsibilities updated by January 15, 2021. Process will begin for all new client intakes by December 14, 2020. Clinical Supervisor will review Merakey's Consumer Rights Policy 709.30 during December's D&A group supervision meeting
709.31 (a) LICENSURE Data collection system § 709.31. Data collection system. (a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
Observations Based on an onsite licensing inspection, the facility failed to have a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.The facility failed to provide the documentation required to complete the inspection of client records. Electronic records were incomplete and paper records were not able to be located These findings were reviewed with project staff during the licensing process.	Plan of Correction In order to better provide the documentation required to complete the inspection of client records, Clinic Director will institute the following: 1) Clinic Director will request Auditor laptops in advance and check the necessary access to records is provided. 2) Clinic Director will upload the Welcome Packet. 3) Clinic Director will request an IT person be available on site to address any technological issues that may arise. 4) Clinic Director will ensure that all printed documents will be uploaded into the electronic record and properly labeled. 5) Clinic Director will ensure charts are printed in advance.
709.34 (a) (1) 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: (1) Physical assault or sexual assault by staff or a client.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020, the project failed to provide procedures for responding to a physical assault or sexual assault by staff or a client. These findings were reviewed with project staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
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.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020 the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises. These findings were reviewed with project staff during the licensing process.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting Policy now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
709.34 (a) (3) 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: (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020, the project failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. These findings were reviewed with project staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting Policy now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
709.34 (a) (4) 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: (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020, the project failed to develop and implement procedures in responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. These findings were reviewed with project staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting Policy now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
709.34 (a) (5) 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: (5) Theft, burglary, break-in or similar incident at the facility.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility. These findings were reviewed with project staff during the licensing process.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting Policy now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
709.34 (a) (6) 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: (6) Event at the facility requiring the presence of police, fire or ambulance personnel.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.These findings were reviewed with project staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting Policy now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
709.34 (a) (7) 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: (7) Fire or structural damage to the facility.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020, the project failed to develop and implement procedures in responding to fire or structural damage to the facility. These findings were reviewed with project staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting Policy now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
709.34 (a) (8) 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: (8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
Observations Based on a review of the project ' s policy and procedure manual on October 29, 2020, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.These findings were reviewed with project staff during the licensing process.This is a repeat citation from November 8, 2019.	Plan of Correction Clinical Supervisor will review Merakey's Unusual Incidents Policy 709.34 during December's D&A group supervision meeting. In addition, the Clinical Supervisor will monitor all reported incidents to ensure proper reporting procedures are being followed. Director of Quality Management will do a retrospective review of our regular Merakey incidents by running reports quarterly to see if any of the reports from D&A staff met the criteria but were NOT reported to DDAP. The Merakey Unusual Incident Reporting Policy now reflects the reporting of unusual incidents with specific language that addresses: (1) Physical assault or sexual assault by staff or a client. (2) Selling or use of illicit drugs on the premises (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. (4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. (5) Theft, burglary, break-in or similar incident at the facility. (6) Event at the facility requiring the presence of police, fire or ambulance personnel. (7) Fire or structural damage to the facility. (8) Outbreak of a contagious disease requiring Center Disease Control (CDC) notification.
715.9(a)(1) LICENSURE Intake (a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall: (1) Verify that the individual has reached 18 years of age.
Observations Based on one of two buprenorphine client records reviewed, the facility failed to provide documentation verifying the client has reached 18 years of age.Client # 5 was admitted on March 30, 2020 and was still active at the time of the inspection. There was no identification provided in the client electronic record. This clients paper record could not be located by facility staff.These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Clinic Director identified that client file for Client #5 was created in wrong color hard chart. Charts are color coded by program type. Clinic Director will re-file chart in correct color binder by December 15, 2020. Clinical Supervisor will review all records during case consultation every 90 days and upon discharge. Intake Coordinator will review all new intakes upon completion of intake paperwork. Therapist will utilize a tracker form to ensure all necessary documentation is completed. Tracker is reviewed in regularly monthly supervision with Clinical Supervisor.
715.9(a)(2) LICENSURE Intake (a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall: (2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
Observations Based on one of two buprenorphine client records reviewed, the facility failed to provide documentation verifying the client's identity and age.Client # 5 was admitted on March 30, 2020 and was still active at the time of the inspection. There was no identification provided in the client electronic record. This clients paper record could not be located by facility staff.These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Clinic Director identified that client file for Client #5 was created in wrong color hard chart. Charts are color coded by program type. Clinic Director will re-file chart in correct color binder by December 15, 2020. Intake Coordinator will review all new intakes upon completion of intake paperwork to verify client's identity and age. Therapist will utilize a tracker form to ensure all necessary documentation is completed. Tracker is reviewed in regularly monthly supervision with Clinical Supervisor.
715.9(a)(3) LICENSURE Intake (a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall: (3) Obtain a drug use history and current drug use status of the individual.
Observations Based on one of two client records reviewed, the facility failed to provide documentation of obtaining a drug use history and current drug use status of the individual.Client # 5 was admitted on March 30, 2020 and was still active at the time of the inspection. There was no documentation of drug use history and current drug use status provided in the client electronic record. This clients paper record could not be located by facility staff.These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Clinic Director identified that client file for Client #5 was created in wrong color hard chart. Charts are color coded by program type. Clinic Director will re-file chart in correct color binder by December 15, 2020. Intake Coordinator will review all new intakes upon completion of intake paperwork to ensure drug use history and current drug use status has been documented. Therapist will utilize a tracker form to ensure all necessary documentation is completed. Tracker is reviewed in regularly monthly supervision with Clinical Supervisor.
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.
Observations Based on one of two buprenorphine client records reviewed, the facility failed to provide documentation of an average of 2.5 hours of psychotherapy per month during the client 's first 2 years, 1 hour of which shall be individual psychotherapy. Client # 5 was admitted on March 30, 2020 and was still active at the time of the inspection. There was no documentation of psychotherapy in the client electronic record. This clients paper record could not be located by facility staff.These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Clinic Director identified that client file for Client #5 was created in wrong color hard chart. Charts are color coded by program type. Clinic Director will re-file chart in correct color binder by December 15, 2020. Psychotherapy hours are tracked on an appointment calendar to ensure all clients are meeting requirement. If clients are missing appointments, Therapist will discuss in Supervision to determine what further interventions are necessary or if discharge is needed. System generated reports are being utilized weekly to monitor to ensure attendance. If psychotherapy requirements are not being met, client will be discharged for disengagement.
709.91(b)(4) LICENSURE Intake and admission 709.91. Intake and admission. (b) Intake procedures shall include documentation of: (4) Consent to treatment.
Observations Based on two of five client records reviewed, the facility failed to provide documentation of the acknowledgement of a consent to treatment in client records # 4 and # 5. Client # 4 was admitted on June 23, 2020 and was discharged on October 20, 2020. A consent to treatment form in the client record did not document verbal acknowledgement or a signature.Client # 5 was admitted on March 30, 2020 and was still active at the time of the inspection. A consent to treatment form in the client record did not document verbal acknowledgement or a signature.These findings were reviewed with project staff during the licensing process.	Plan of Correction Starting Dec 21st, 2020 all D&A Admission Paperwork that includes consents and releases will be completed in person at our physical site by the Intake Coordinator and new Client. Paperwork will be checked for completion by the Intake Coordinator and uploaded into the Electronic Health Record as well as filed in the physical chart. In addition, clients admitted to the program prior to Dec 21st, 2020 will receive paperwork via postal mail to sign and return to the office. This will be the responsibility of our administrative support person under the supervision of our Office Manager. This attempt to get the physical signature will be documented into the client record. This matter will be referred to the Quality Compliance Division of QCO for investigation and follow up, which may include restitution for any identified overpayment.
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.
Observations Based on a three of five client records reviewed, the facility failed to provide documentation of case consultations involving staff other than the clinician or occuring according to the facility policy and procedure manual every ninety days for the first year after admission in client record's # 2, 3, and 5.Client # 2 was admitted on November 6, 2019 and was still active at the time of the inspection. Case consultations were to be completed by February 6, 2020, May 6, 2020, August 6, 2020 but none occurred. Client # 3 was admitted on March 4, 2020 and was still active at the time of the inspection. Case consultations are not being completed by staff other than the clinician. Client # 5 was admitted on March 30, 2020 and was still active at the time of the inspection. Case consultations were to be completed by June 30, 2020 and September 30, 2020 but none occurred. These findings were reviewed with project staff during the licensing process.	Plan of Correction Plan of Correction: Therapists have now been provided with a tracker to monitor when case consultations are due. The Clinical Supervisor/CAADC is reviewing and signing off on all case consultations. Program determined that Auditor did not have access to run report to review case consultations while conducting on-site visit. In order to better provide the documentation required to complete the inspection of client records, we will institute the following: 1) We will request Auditor laptops in advance and check the necessary access to records is provided. 2) We will upload the Welcome Packet. 3) We will request an IT person be available on site to address any technological issues that may arise. 4) We will ensure that all printed documents will be uploaded into the electronic record and properly labeled. 5) We will print charts in advance provided we have knowledge of what charts are being requested.