INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22, 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 Pennsylvania 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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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 a physical plant inspection it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of employee #4 ' s office, as the door was open and the counseling session could be heard from the conference room.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The requirement of ensuring privacy so that counseling sessions cannot be seen or heard outside the counseling room. All staff members will be informed during group supervision that they must ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 12/16/2021
2. White noise machines will be purchased and placed outside of each counseling area in order to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
Completion date - 01/01/2022-Ongoing
3. Ongoing monitoring conducted by the Outpatient Director and Clinical Supervisor to ensure that counseling sessions cannot be seen or heard outside the counseling room in order to ensure privacy is maintained.
Completion date - 12/16/2021-Ongoing
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drills from November 2019 through October 2021, the facility failed to identify exit routes used in all documented fire drills These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. The Fire Drill Documentation form is in the process of being revised to reflect the required need to address the exit route used.
Completion date - 12/16/2021
2. The approved Fire Drill Documentation form will be reviewed with all OPT staff in Group Supervision. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 12/16/2021
3. Ongoing monitoring and utilization of the form will be completed during fire drills on the premises by the Outpatient Director or designee when completed.
Completion date - 12/16/2021-Ongoing
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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 the review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record reviewed. Client #7 was admitted on February 8, 2021 and discharged on September 13, 2021. There was documentation that a phone call was made to probation on September 13, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. All staff members will be informed during group supervision that they shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. At no time shall Information be permitted to be released to any party without an informed and voluntary consent from the client for the disclosure of information contained in the client record. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 12/16/2021
2. Staff will obtain an informed and voluntary consent with every current, as well as all new, clients for the disclosure of information contained in the client record.
Completion date - 12/16/2021-Ongoing
3. Ongoing monitoring of completed releases is conducted through review by the Outpatient Director and Clinical Supervisor to ensure that all releases meet the requirements.
Completion date - 12/16/2021-Ongoing
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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 the review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record reviewed. Client #7 was admitted on February 8, 2021 and discharged on September 13, 2021. There was documentation that a phone call was made to probation on September 13, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
1. All staff members will be informed during group supervision that releases are not permitted to completed as noting "Entire Record" as permissible for release to the identified party. Staff will complete a training acknowledgment form that will be filed in their supervision record.
Completion date - 12/16/2021
2. New releases will be completed with each current client, as well as all new clients, to reflect that only permissible items be acknowledged for release to the identified party. Reasons for release will be limited to the following information;
- Nature of the project
- Brief description of progress
- Whether the client is/is not in treatment
- Client's prognosis
- Whether the client relapsed
Completion date - 12/16/2021-Ongoing
3. Ongoing monitoring of completed releases is conducted through review by the Outpatient Director and Clinical Supervisor to ensure that all releases meet the requirements.
Completion date - 12/16/2021-Ongoing
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