INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on November 28, 2023, through November 29, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on physical plant inspection, conducted on November 29, 2023 at approximately 10 am, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner.
During the inspection, there was graffiti on the wall and the paper towel dispenser in the client bathrooms in the client waiting room. Additionally, there were tiles missing and cracked on the floor of the second-floor staff bathroom.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The tiles in the bathroom were fixed on 12/11/23.
Graffiti was removed from the client bathroom on 12/20/23.
Bi-weekly, a facility walk-through will be completed by the Program's Office Manager. The results of the facility checklist will be reviewed with the management team to ensure immediate action.
As facility needs or repairs arise, the Program Director or Office Manager will submit a ticket to have these issues addressed.
A memo will be sent to all staff to remind them of the importance of reporting the need for facility repair immediately.
There will continue to be complaint boxes located on both floors of the building.
The Office Manager will check the mailbox weekly and address concerns within 5 business days. For resolution that will take longer than 5 business days, updates will be documented on weekly walk-through reports.
Clients will continue to have the opportunity to report facility issues as they are observed. Counselors will also review this process in group sessions.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The policy and procedure manual stated that the successfully discharged client will be notified, in writing, with a follow up letter 30 days after discharge.
Client #4 was admitted on May 28 2020, and was discharged on March 6, 2023. The record had documentation of outreach following successful discharge; however, the form was not dated and therefore could not be verified that contact was made within the facility's documented procedural time frame.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A memo was sent to staff on 11/29/23 stating that moving forward they must ensure they are putting the date on the discharge letter.
Effective 12/1/23, counselors will date the discharge notification letter for the date the letter is being mailed out. This is to occur within 7 days of discharge, to adhere to the program's policy and procedures.
The Clinical Supervisor will review all discharge documentation completed by the counselors within 2 business days to ensure that all pertinent information is captured in its entirety, and includes the appropriate signatures and dates as required. Documentation that is deficient in any of the areas defined will be sent back to the counselor for immediate correction.
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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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 1 was on October 14, 2021 and was active at the time of inspection. The release of information form to the funding source was signed by the client on October 14, 2021 and the release form expired on October 14, 2023. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after October 14, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Releases for client #1 were completed on 11/30/2023.
In January 2022, the program changed the listed due date on releases of information to be a condition versus an actual date. Staff have been trained on this change for our releases and understand the change.
However, a staff utilized the incorrect release, and used an expired document.
Blank copies of release forms will be maintained in staff copy rooms for staff to easily access these items. As well as to prevent staff from using an out-of-date document.
Staff will review all active client records assigned to their caseloads with admission dates prior to 11/20/23 to ensure that the correct releases are being utilized and have not expired. Any charts found to have expired releases, or that are using the incorrect release, will be updated within 2 business days of the discovery (where able), or upon the next scheduled counseling session.
Additionally, all admission charts will be reviewed by the intake supervisor within 2 business days of the admission.
Ongoing monitoring of completed releases is conducted through monthly internal chart audits through our Data Management Team. If during the internal audit, a release is expired, Program Director and Clinical Supervisor will be informed. The assigned counselor will then complete an updated ROI.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotherapy, in one of one applicable patient records reviewed.
Patient #2 was admitted March 3, 2023 and was active at the time of inspection. The record of service and progress notes in the record documented ninety minutes of psychotherapy during the month of August 2023 and sixty minutes of psychotherapy during the month of October 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/14/23 the Program Director shared and provided a copy of regulation 715.19 to the clinical team in order for them to reference these guidelines when scheduling.
As the Program Director sends weekly updates on services in relation to financial requirements, the Director will remind counselors that clients must continue to be scheduled for the appropriate regulatory hours they require, regardless of whether a client also achieved their monthly financial requirements.
The team will document canceled or missed appointments, which will indicate the attempts of scheduling clients accordingly.
The Data Management Team will run reports that will be shared with the program management team. Reports will be run by the 15th and 31st of each month. These reports will assist the program with the identification of clients who may not have met their required hours as regulated by state requirements. Any client identified as deficient through this reporting process will be scheduled accordingly to ensure compliance by the month's end.
Reports will be reviewed in supervision with counselors to ensure awareness of client's monthly service levels.
Treatment session attendance, in relation to the duration of program enrollment will be reviewed as part of the quarterly chart audit process to ensure compliance.
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include an admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, in one of one applicable patient record reviewed.
Patient #5 was transferred out to another narcotic treatment program on October 6, 2023. There was no documentation, in the record, that the narcotic treatment program transferred any patient files to the receiving narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 12/1/23, the staff facilitating this transfer to an inpatient facility, will scan and upload the entire transfer packet into the client chart to document what was sent to the identified facility.
Prior to the submission of transfer paperwork to any external entity, the staff initiating the transfer will submit prospective documentation to the assigned supervisor for review and final approval.
Following supervisory approval, the staff will then upload all approved transfer documentation to the external agency as requested. Both the supervisor and the staff initiating the transfer will sign off and date the approved documentation via a transfer documentation checklist.
Ongoing monitoring of uploading transfer packets for inpatient admission will be conducted through monthly internal chart audits, completed by the Data Management Team.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of an annual physical examination given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician in one of seven patient records reviewed.
Patient #3 was admitted August 1, 2011 and was active at the time of inspection. There was no annual physical exam documented for 2023. The last physical exam was documented on August 26, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Director and Nurse Supervisor utilize tracking forms to schedule annuals timely and accordingly.
When the program encounters a vacancy for the Nurse Supervisor position, the oversight of these trackers will be completed by the Nurse Director.
Clients will be scheduled at least two weeks prior to their annual anniversary date to allow some margin for those who may miss their scheduled annual physical reevaluation appointment date. Those who miss will be re-scheduled within one week of the missed appointment date. Staff will document missed physical appointments in the client record to verify the program's attempts at scheduling the appointment, as well as documenting client noncompliance.
Continued noncompliance will result in a referral to the physician documenting future expectations to become compliant.
Ongoing monitoring of scheduling annuals will be conducted through monthly internal chart audits, completed by the Data Management Team. At minimum, 5% of the total program census will be audited per month.
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