INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on December 4-6, 2019 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 Parkside Recovery 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
During an annual licensing inspection conducted on December 4-6, 2019, 25 personnel records were reviewed. Five counselors with qualifying master ' s degrees did not have a practicum that took place in a drug and alcohol setting. Each individual's written training plan did not specifically address a plan to achieve counseling competency in chemical dependency issues.
Employee #10 was hired August 12, 2019 and was still current in the position of counselor. The individual's written training plan did not specifically address a plan to achieve counseling competency in chemical dependency issues.
Employee #12 was hired July 8, 2019 and was still current in the position of counselor. The individual's written training plan did not specifically address a plan to achieve counseling competency in chemical dependency issues.
Employee #16 was hired on August 12, 2019 and was still current in the position of counselor. The individual's written training plan did not specifically address a plan to achieve counseling competency in chemical dependency issues.
Employee #17 was hired on June 24, 2019 and was still current in the position of counselor. The individual's written training plan did not specifically address a plan to achieve counseling competency in chemical dependency issues.
Employee #20 was hired January 28, 2019 and was still current in the position of counselor. The individual's written training plan did not specifically address a plan to achieve counseling competency in chemical dependency issues.
These finding were discussed with staff during the licensing process.
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Plan of Correction
The Facility Director worked with supervisors and employees #10, #12, #16, #17, and #20 training plans were updated by 12/9/2019 to include the statement "to achieve counseling competencies in chemical dependency issues." Effective 12/6/2019 and going forward this statement will be reflected on employees training plans who do not hire have experience in a drug and alcohol setting. The Facility Director will be responsible for ensuring compliance with this process and standard. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
During a physical site inspection of the facility on December 5, 2019, the nonresidential facility failed to provide a wall mirror in each bathroom.
There were two client bathrooms that did not have wall mirrors.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director advised designated personnel to place a work order on 12/5/2019 for wall mirrors in the two client bathrooms. Facility Director checked the bathrooms on 2/5/2020 and learned the wall mirror work order was not fulfilled. The Facility Director put a work order in on 2/5/2020 for the wall mirrors to be placed immediately. The Facility Director will follow-up twice a week on this request until completed. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
During an annual licensing inspection conducted on December 4-6, 2019, 25 personnel records were reviewed. Five employees were not instructed in the use of the fire extinguisher upon employment.
Employee #9 was hired May 3, 2019 and was not instructed in the use of the fire extinguisher upon employment.
Employee #12 was hired July 8, 2019 and was not instructed in the use of the fire extinguisher upon employment.
Employee #18 was hired August 12, 2019 and was not instructed in the use of the fire extinguisher upon employment.
Employee #19 was hired June 24, 2019 and was not instructed in the use of the fire extinguisher upon employment.
Employee #20 was hired January 28, 2019 and was not instructed in the use of the fire extinguisher upon employment.
These finding were discussed with staff during the licensing process.
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Plan of Correction
By 12/6/2019, Facility Director added to the New Hire To-Do Checklist the need for new hires to be instructed on how to use a fire extinguisher. The Facility Director notes that this must be completed with 7-days of hire. Beginning 12/6/2019 and moving forward Facility Director will advise new hires via email on how to access the training tool used to instruct employees on how to use a fire extinguisher and that it is due by 7th day after hire. Employees #9, #12, #18, #19, and #20 completed the training but not within 7-days of hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
During an annual licensing inspection conducted on December 4-6, 2019, 25 personnel records were reviewed. Six employees were not trained to perform assigned tasks during emergencies.
Employee #9 was hired May 3, 2019 and was not trained to perform assigned tasks during emergencies.
Employee #12 was hired July 8, 2019 and was not trained to perform assigned tasks during emergencies.
Employee #17 was hired on June 24, 2019 and was not trained to perform assigned tasks during emergencies.
Employee #18 was hired August 12, 2019 and was not trained to perform assigned tasks during emergencies.
Employee #19 was hired June 24, 2019 and was not trained to perform assigned tasks during emergencies.
Employee #20 was hired January 28, 2019 and was not trained to perform assigned tasks during emergencies.
These finding were discussed with staff during the licensing process.
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Plan of Correction
By 12/6/2019, Facility Director added to the New Hire To-Do Checklist the need for new hires to be made aware of assigned tasks during emergencies. The Facility Director notes that this must be completed with 7-days of hire. Beginning 12/6/2019 and moving forward Facility Director will advise new hires via email on how to access the training tool used to instruct employees on how assigned tasks during emergencies and that it is due by 7th day after hire. Employees #9, #12, #18, #19, and #20 completed the training but not within 7-days of hire. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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
During a review of the fire drill record on December 4-6, 2019, the nonresidential facility failed to maintain a written fire drill record including the time, problems encountered and whether the fire alarm or smoke detector was operative.
Fire drills for October 2019 and November 2019 did not include the exact time that the fire drill took place. Fire drills from January 2019 through November 2019 did not include problems encountered and whether the fire alarm or smoke detector were operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director updated the Fire Drill form on 12/6/2019 to include the missing elements (time of drill, problems encountered, if alarm/detector was operative). This form was used for drills in December 2019, January 2020, and will continue to be used moving forward. The Facility Director will be responsible for maintaining compliance. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During a review of the Policy and Procedure manual on December 4-6, 2019, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
The project director did not annually update and sign the project policy and procedure manual.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 12/9/2019 Facility Director added to her DDAP Inspection Prep List the need to print and ensure signatures of the Policy and Procedure manual. The Facility Director will ensure this is completed on an annual basis. The Facility Director and Project Director signed the manual on 12/6/2019. |
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 a review of client records on December 4-6, 2019, the facility failed to document a completed informed and voluntary consent to disclose information in client records # 12 and 17.
Client #12 was admitted on December 27, 2016 and discharged on March 28, 2019. An informed and voluntary consent to disclose form, to the funding source expired on December 6, 2018. There was no new consent to disclose information form in the client's file. The facility director confirmed that between the expiration date of the release and the discharge date of the client, billing was submitted to the funding source without a valid consent to disclose. In addition, a consent to disclose information form to a laboratory expired on December 6, 2018. Urine screenings were conducted on January 24, 2019 and February 15, 2019 and sent to the laboratory. No updated consent to disclose was obtained from the client for the laboratory was documented in the client's file.
Client #17 was admitted on March 6, 2008 and was still active at the time of the inspection. An informed and voluntary consent to disclose form for the funding source, expired on September 27, 2018. There was no updated consent to disclose information form in the client's file. The facility director confirmed that between the expiration date of the release and the time of the inspection, billing was submitted to the funding source without a proper release.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to updating releases of information as they expire. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including updating release of information as they expire. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of 18 client records on December 4-6, 2019, the facility failed to obtain a completed informed and voluntary consent to disclose information form, as to whom disclosure is to be made was missing or incorrectly completed in client records #6, 9, 16 and 18.
Client #6 was admitted on November 6, 2018 and was discharged on June 24, 2019. A consent to disclose form, dated November 16, 2018, was incorrectly completed as to whom disclosure was to be made. The release stated it was for the emergency contact however there was no name nor phone number listed.
Client #9 was admitted on August 15, 2018 and was still active at the time of the inspection. A consent to disclose form, dated August 15, 2018, was incorrectly completed in regard to whom disclosure is made. The disclosure stated information was to be released from the funding source to Merakey Parkside Recovery. There was no disclosure of information form for Merakey Parkside Recovery to send information to the funding source for billing purposes.
Client #16 was admitted on August 23, 2019 and was still active at the time of the inspection. A consent to disclose information form dated June 14, 2019 did not include to whom disclosure is to be made.
Client #18 was admitted on April 1, 2019 and discharged on July 24, 2019. Ten consent to disclose forms in the client record, dated March 29, 2019, were incorrectly completed. All ten forms listed Merakey Parkside as the entity obtaining information rather than disclosing the information. The organizations listed on these releases included three other treatment facilities, three government agencies, one emergency contact, one laboratory, one funding source and one transportation service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to accurate completion of releases of information. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including accurate completion of releases of information. This training will be provided as new staff are hired and on a annual basis to all staff. |
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 a review of 18 client records on December 4-6, 2019, 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 records # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 15, 16 and 18. In addition, client record #14, does not include what specific information may be disclosed, as this section of the form was blank.
Client #1 was admitted on March 21, 2019 and was current at the time of the inspection. Four informed and voluntary consent forms dated March 21, 2019 in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to a government agency, two funding sources and the other was to the emergency contact.
Client #2 was admitted on March 27, 2019 and was discharged on November 27, 2019. Four informed and voluntary consent forms dated March 27, 2019 in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to a government agency, two funding sources and the other was to the emergency contact.
Client #3 was admitted on September 13, 1910 and was current at the time of the inspection. Five informed and voluntary consent forms dated September 6, 2018 in the client ' s record had no information identified as to what was to be disclosed. The disclosure forms were to the emergency contact, two funding sources, the laboratory and the other was to transportation.
Client #4 was admitted on March 29, 2019 and was current at the time of the inspection. Two informed and voluntary consent forms dated March 29, 2019 in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to two funding sources.
Client #5 was admitted on January 3, 2019 and was discharged on June 24, 2019. Four informed and voluntary consent forms dated March 27, 2019 in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to a government agency, two funding sources and the other was to the emergency contact.
Client #6 was admitted on November 16, 2018 and was discharged on June 24, 2019. Seven informed and voluntary consent forms dated November 16, 2018 in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to a government agency, two funding sources, another treatment facility, laboratory, transportation and the other was to the emergency contact.
Client #10 was admitted on April 9, 2012 and was current at the time of the inspection. Six informed and voluntary consent forms dated March 21, 2019 in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to two funding sources, a laboratory, a transportation service, an emergency contact and one that was missing recipient.
Client #8 was admitted on March 8, 2018 and was still active at the time of the inspection. Two informed and voluntary consent forms, both dated Januarys 22, 2019, permitted the entire record to be released the funding source and a government agency.
Client #9 was admitted on August 15, 2018 and was still active at the time of the inspection. An informed and voluntary consent form to a government agency, dated August 16, 2019 permitted the entire record to be released.
Client #11 was admitted on February 26, 2019 and was still active at the time of the inspection. An informed and voluntary consent form to an individual did not include what specific information could be disclosed. In addition, seven disclosure forms in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to two government agencies, a funding source, a transportation service, an emergency contact and two other treatment facilities.
Client #14 was admitted on June 4, 2007 and was still active at the time of the inspection. In four informed and voluntary consent forms, the form did not include information on what may be disclosed. The disclosure forms were to the funding source, emergency contact, transportation service and another treatment facility.
Client #15 was admitted on December 12, 2006 and was still active at the time of the inspection. Three informed and voluntary consent forms, dated January 18, 2019, permitted the entire record to be released to the funding source, and two government agencies.
Client #16 was admitted on August 23, 2019 and was still active at the time of the inspection. Three informed and voluntary consent forms, dated August 6, 2019, permitted the entire record to be released to the funding source and two government agencies.
Client #18 was admitted on April 1, 2019 and discharged on July 24, 2019. Four informed and voluntary consent forms in the client ' s record had the box for "other" information to be disclosed checked but did not indicate what was to be included as other information. The disclosure forms were to a government agency, a funding source, a transportation service, and another treatment facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project facilitated a Confidentiality training on January 10, 2020 which included a review of 4 Pa. Code 255.5 and limits of confidentiality. This training will be provided on an annual basis. As new staff are hired, supervision will include discussion around confidentiality and will be reviewed as needed will all staff. The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to accurate completion of releases of information. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including accurate completion of releases of information. This training will be provided as new staff are hired and on a annual basis to all staff. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of 18 client records on December 4-6, 2019, the facility failed to document an informed and voluntary consent to disclose forms in client records #11 and #10. The disclosure forms did not include the purpose of disclosure.
Client #10 was admitted on April 9, 2012 and was current at the time of the inspection. A consent to disclose information form, dated March 21, 2019, did not include the recipient name or purpose of disclosure.
Client #11 was admitted on February 26, 2019 and was still active at the time of the inspection. A consent to disclose information form, dated June 21, 2019, to an individual, did not include the purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to accurate completion of releases of information. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including accurate completion of releases of information. This training will be provided as new staff are hired and on a annual basis to all staff. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of 18 client records on December 4-6, 2019, the facility failed to document a completed informed and voluntary consent to disclose form in one of the records, as the disclosure form did not include a dated signature of the witness.
Client #11 was admitted on February 26, 2019 and was still active at the time of the inspection. A consent to disclose information form, dated June 21, 2019, to an individual, did not include a dated signature of the witness.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to accurate completion of releases of information. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including accurate completion of releases of information. This training will be provided as new staff are hired and on a annual basis to all staff. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of 18 client records on December 4-6, 2019, the facility failed to document an informed and voluntary consent in two of the client records, as the consent forms did not include a date, event or condition upon which the consents will expire.
Client #3 was admitted on September 13, 2010 and was still active at the time of the inspection. Five informed and voluntary consent to disclose information forms, dated September 6, 2018, to an emergency contact, two funding agencies, one transportation and one laboratory did not include a date, event or condition upon which the consents will expire.
Client #11 was admitted on February 26, 2019 and was still active at the time of the inspection. An informed and voluntary consent to disclose information form to disclose information form, dated June 21, 2019, to an individual, did not include a date, event or condition upon which the consents will expire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to accurate completion of releases of information. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including accurate completion of releases of information. This training will be provided as new staff are hired and on a annual basis to all staff. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of 18 client records on December 4-6, 2019, the facility failed to document a completed informed and voluntary consent in client records #11 and 18, as the consent forms did not include whether the client was offered a copy of the form.
Client #11 was admitted on February 26, 2019 and was still active at the time of the inspection. An informed and voluntary consent to disclose information form, dated June 21, 2019, to an individual, did not include whether the client was offered a copy of the form.
Client #18 was admitted on April 1, 2019 and discharged on July 24, 2019. An informed and voluntary consent to disclose information form, dated March 29, 2019, to another treatment facility did not include whether the client was offered a copy of the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to accurate completion of releases of information. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including accurate completion of releases of information. This training will be provided as new staff are hired and on a annual basis to all staff. |
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
Based on a review of client records on December 4-6, 2019, the project failed to notify the client, in writing, of the project's decision to involuntarily terminate the client in client record # 13.
Client #13 was admitted on October 20, 2016 and discharged on July 24, 2019. There was no written documentation of the decision to involuntary terminate the client ' s treatment at the project.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the need for written documentation informing a client when they have been involuntary terminated with the Clinical Director and Clinical Supervisors. Effective 12/6/2019 and moving forward the Project will providers letters directly to client or send to last known address for all involuntary discharges. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
During a review of policies and procedures on December 4-6, 2019, the narcotic treatment program failed to follow their system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
The program failed to follow their policy and procedure manual for the dispensing of medication.
These findings were reviewed with the program staff during the licensing process.
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Plan of Correction
In March 2018 the Facility instituted a new method of identifying individuals prior to being medicated as the use of medication cards would often cause delays in service. Leading up to the change, discussions took place between all levels of staff and the persons in recovery to prepare for the change. The new process was detailed and questions were answered as they arose. The Medication Administration Policy was formally updated June 2018 once the new process was deemed to be working effectively. The Project now has a formal Policy Review Committee that meets at least once a month to review and update policies. When significant changes are made to policies staff are advised in a staff meeting, held monthly. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of client records on December 4-6, 2019, the program failed to obtain and document a random monthly urinalysis for patients # 14 and 15.
Patient #14 was admitted on June 4, 2007 and was still active at the time of the inspection. There was no documentation of a urinalysis being conducted for the month of November 2019.
Patient #15 was admitted on December 12, 2006 and was still active at the time of the inspection. There was no documentation of a urinalysis being conducted for the month of October 2019.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Upon further facility review, #14 had a UDS on 11/5/2019 which is available for review. #15 did not have a UDS in October 2019. Facility will work to determine what may have happened with the EHR system that this occurred. Counselors will be reminded on February 17th, 2020 if it near the end of the month and they have not reviewed a UDS for a person in recovery to consult with supervisors to determine if the EHR has an upcoming alert for one or if this was somehow missed. |
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
Based on a review of patient records on December 4-6, 2019, the program failed to document an annual clinical evaluation of the patient in patient records # 12, 13 and 14.
Patient #12 was admitted on December 27, 2016 and discharged on March 28, 2019. The most recent annual evaluation was due no later than December 27, 2018; however, it was not documented as of the date of the inspection.
Patient #13 was admitted on October 20, 2016 and discharged on July 24, 2019. The most recent annual evaluation was due no later than October 20, 2018; however, it was not documented as of the date of the inspection.
Patient #14 was admitted on June 4, 2007 and was still active at the time of the inspection. The most recent annual evaluation was due no later than June 4, 2019; however, it was not documented as of the date of the inspection.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Project will continue to conduct monthly chart audits by designated personnel. During these audits as deficiencies are noted Clinical Supervisors will provide supervision to counselors around documentation standards specific to completion of annual clinical evaluation. The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including completion of annual clinical evaluation. This training will be provided as new staff are hired and on a annual basis to all staff. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records on December 4-6, 2019, there was no documentation that the clients received counseling services according to their individual treatment plan in client record #'s 8, 9, 11, 12, 13, 15 and 17.
Client #8 was admitted on March 8, 2018 and was still active at the time of the inspection. The treatment plan, dated March 22, 2019, stated biweekly individual sessions. The file indicated that the client had not received individual sessions between May 9 - June 18, July 18-August 13, September 12 - October 24, 2019. In addition, a progress note, submitted November 21, 2019 by the client's counselor, stated the client "was gracious enough to sacrifice his scheduled individual session time for prior weeks to ensure others had the time they needed with therapist to address urgent issues".
Client #9 was admitted on August 15, 2018 and was still active at the time of the inspection. The treatment plan, dated November 15, 2019, stated weekly individual sessions. The file indicated that the client had not received individual sessions between November 16 - December 2, 2019.
Client #11 was admitted on February 26, 2019 and was still active at the time of the inspection. The treatment plan, dated March 1, 2019, stated weekly individual sessions. The file indicated that the client had not received individual sessions between September 14-26, and October 12-30, 2019.
Client #12 was admitted on December 27, 2016 and discharged on March 28, 2019. The treatment plan, dated February 13, 2019, stated individual sessions twice a month. The file indicated that the client only received one individual session during the months of December 2018 and January 2019.
Client #13 was admitted on October 20, 2016 and discharged on July 24, 2019. The treatment plan, dated April 26, 2019, indicated biweekly individual sessions. The file indicated that the client had not received individual sessions between March 7-April 25, and April 27-June 9, 2019 with no further individual sessions after June 10, 2019.
Client #15 was admitted on December 12, 2006 and was still active at the time of the inspection. The treatment plan, dated October 29, 2019, indicated weekly individual sessions. The file indicated that the client had not received individual sessions between October 16-28, 2019.
Client #17 was admitted on March 6, 2008 and was still active at the time of the inspection. The treatment plan, dated October 1, 2019, indicated weekly individual sessions. The file indicated that the client had not received individual sessions between August 27-September 11, September 13-30, October 2-24, October 31-November 12, 2019 with no further individual sessions after October 13, 2019.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project has created a Comprehensive Documentation training that will be facilitated on 3/6/2020 which will further review documentation standards including writing a treatment plan based on the amount of services being received by a client. This training will be provided as new staff are hired and on a annual basis to all staff. |