INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 17, 2024 through October 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in eleven of eleven applicable personnel records reviewed.
Employee # 9 was hired as a counselor on July 24, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than July 24, 2024. Both trainings were not completed at the time of the inspection.
Employee # 10 was hired as a counselor on January 9, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than January 9, 2024. Both trainings were not completed at the time of the inspection.
Employee # 11 was hired as a counselor on May 22, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than May 22, 2024. Both trainings were not completed at the time of the inspection.
Employee # 12 was hired as a counselor on June 26, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than June 27, 2024. Both trainings were not completed at the time of the inspection.
Employee # 13 was hired as a counselor on October 31, 2022 and was due to have the HIV/AIDS training and the TB/STD training no later than October 31, 2023. Both trainings were not completed at the time of the inspection.
Employee # 14 was hired as a counselor on February 22, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than February 22, 2024. Both trainings were not completed at the time of the inspection.
Employee # 16 was hired as a counselor on July 24, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than July 24, 2024. Both trainings were not completed at the time of the inspection.
Employee # 17 was hired as a counselor on September 18, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than September 18, 2024. Both trainings were not completed at the time of the inspection.
Employee # 18 was hired as an engagement specialist on April 11, 2022 and was due to have the HIV/AIDS training and the TB/STD training no later than April 11, 2024. Both trainings were not completed at the time of the inspection.
Employee # 19 was hired as an engagement specialist on May 23, 2022 and was due to have the HIV/AIDS training and the TB/STD training no later than May 23, 2024. Both trainings were not completed at the time of the inspection.
Employee # 20 was hired as an engagement specialist on May 23, 2022 and was due to have the HIV/AIDS training and the TB/STD training no later than May 23, 2024. Both trainings were not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director or Designee will utilize a spreadsheet to monitor mandatory Communicable Disease Training completion as well as LMS reports.
The Facility Director or Designee and Clinical Supervisors will ensure that Counselors and Counselor Assistants receive the training within a year of hire, and all other staff within 2 years of hire.
Following the completion of training attended by staff, certificate will be uploaded or logged into the training within the Learning Management System (LMS) by staff who completed the training.
The Facility Director or Designee will review, with each Clinical Supervisor, the training requirements for their assigned staff in weekly supervision.
Clinical Supervisors will review training requirements with their assigned staff and will review completed training uploads in LMS during supervision.
As Counselors complete training the Clinical Supervisor will notify the Facility Director or Designee, who then updates the training spreadsheet to reflect the new hours. Spreadsheet will minimally be updated weekly.
Training status and review of LMS will be documented in a supervision note.
Upon hire, staff will be sent information to register for HIV/AIDS and TB/STD training.
The Facility Director or Designee will send emails that include any newly released mandatory training opportunities and will also provide 30-day notifications prior to due dates.
Employees #9, 10, 11, 12, 13, 14, 16, 17, 18, 19 and 20 will obtain HIV/AIDS and TB/STD training by 2/28/25. Upon completion, certificates will be uploaded in LMS and training tracker will be updated.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of annual training, during the facility's July 1, 2023 through June 30, 2024 training year, in two of three applicable personnel records reviewed.
Employee # 3 was hired as a clinical supervisor on December 20, 2021. The personnel record documented 8 hours and 10 minutes of training received during the reviewed training year.
Employee # 5 was hired as a clinical supervisor on February 12, 2018. The personnel record documented 2 hours and 10 minutes of training received during the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director or Designee will utilize a spreadsheet to monitor annual training hours for the Clinical Supervisors as well LMS reports.
The Facility Director or Designee will ensure that Clinical Supervisors receive at least 12 clock hours of training each year.
Following the completion of training attended by Clinical Supervisor, certificate will be uploaded or logged in Learning Management System (LMS).
The Facility Director or Designee will review, with each Clinical Supervisor, the progress made toward meeting their annual training requirements in weekly supervision. LMS report will be viewed monthly to discuss training hours.
Clinical Supervisor will notify the Facility Director or Designee, who then updates the training spreadsheet to reflect the new hours. Spreadsheet will minimally be updated weekly.
Training status will be documented in a supervision note. All staff will be reminded to utilize LMS for training certificates.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's July 1, 2023 through June 30, 2024 training year, in six of six applicable personnel records reviewed.
Employee # 10 was hired as a counselor on January 9, 2023. The personnel record documented 4 hours and 10 minutes of training received during the training year reviewed.
Employee # 11 was hired as a counselor on May 22, 2023. The personnel record documented 7 hours and 5 minutes of training received during the training year reviewed.
Employee # 12 was hired as a counselor on June 26, 2023. The personnel record documented 22 hours and 30 minutes of training received during the training year reviewed.
Employee # 13 was hired as a counselor on October 31, 2022. The personnel record documented 4 hours and 3 minutes of training received during the training year reviewed.
Employee # 14 was hired as a counselor on February 22, 2023. The personnel record documented 7 hours and 48 minutes of training received during the training year reviewed.
Employee # 15 was hired as a counselor on September 29, 2021. The personnel record documented 7 hours and 48 minutes of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Facility Director or Designee will utilize a spreadsheet and LMS to monitor annual training hours for the Counseling Staff.
The Facility Director or Designee and Clinical Supervisors will ensure that Counselors receive at least 25 clock hours of training each year.
Following the completion of training attended by Counselor, certificate will be uploaded or logged into the training within the Learning Management System (LMS) by Counselor who completed the training.
The Facility Director or Designee will review, with each Clinical Supervisor, the Counselor's progress made toward meeting their annual training requirements in weekly supervision and will utilize the LMS report.
Clinical Supervisors will review training requirements with their assigned staff and will review completed training uploads in LMS during supervision.
Training status will be documented in a supervision note.
The Clinical Supervisor will recommend training opportunities as they arise and will assist in scheduling staff.
The Facility Director or Designee will schedule at least one 4-8 hour onsite training each quarter to provide opportunities for training.
As Counselors complete training the Clinical Supervisor will notify the Facility Director or Designee, who then updates the training spreadsheet to reflect the new hours. Spreadsheet will minimally be updated weekly.
Training status will be a standing supervision agenda item and will be reviewed and documented in each session.
The program will file an exception, if there are unforeseen issues that prohibit a staff from being unable to meet the 25-hour requirement.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At approximately 9:45 AM on October 18, 2024, there was a portable space heater located in Room 251.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The heater was removed from room #251 on 10/18/24.
Monthly, Facilities Supervisor will ensure portable heaters are not found in the building including counseling offices, group rooms, and main areas and document on the facility checklist.
Staff were reminded on 10/18/24 that portable heaters are prohibited from being in the building.
Staff who are found to be noncompliant will be addressed in supervision by the Clinical Supervisor and discussion will be documented in a supervision note. Additional action will be initiated for continued noncompliance, including possible corrective action.
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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, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in five of seven applicable records reviewed.
The facility policy and procedure manual included the following procedures: First, the intake assessment, including a personal history, is to be completed on the day of admission. Second, the intake assessment, including a psychosocial assessment, is to be completed on the day of admission. Third, the case consultation notes are to be completed every six months for the first year in treatment and yearly thereafter.
Client # 1 was admitted on February 8, 2024 and was still active at the time of the inspection. A psychosocial assessment was due to be completed no later than February 8, 2024; however, the assessment was not completed until March 4, 2024. Additionally, a case consultation was due to be completed by August 8, 2024; however, there was no case consultation note documented in the record at the time of the inspection.
Client # 2 was admitted on February 8, 2024 and was still active at the time of the inspection. A personal history was due to be completed no later than February 8, 2024; however, the history was not completed until March 4, 2024.
Client # 5 was admitted on June 14, 2024 and was discharged on August 19, 2024. A personal history was due to be completed no later than June 14, 2024; however, the history was not completed until June 25, 2024. Additionally, a psychosocial assessment was due to be completed no later than June 14, 2024; however, the assessment was not completed until July 23, 2024.
Client # 6 was admitted on February 1, 2022 and was discharged on September 5, 2024. A case consultation was completed on May 9, 2023 and the next case consultation was to be completed by May 9, 2024; however, there was no case consultation note documented in the record prior to discharge.
Client # 7 was admitted on February 26, 2024 and was discharged on September 19, 2024. The personal history was due to be completed no later than February 8, 2024; however, the personal history was not completed until April 30, 2024. Additionally, the psychosocial assessment was due to be completed no later than February 8, 2024; however, the assessment was not completed until April 30, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the ABH Merakey Parkside Recovery Management of Treatment Services Guideline policy, the Intake Counselor is responsible for ensuring that a personal history is completed throughout the intake documents on day one of the admission. The biopsychosocial (SBCA) is completed within 30 days of admission by the counselor.
The Intake Supervisor will hold a supervision session with the Intake Counselor, by 11/18/24. In this supervision session, the Intake Counselor will be retrained on all intake documentation requirements, including the personal history, as well as the timelines associated to its completion. Retraining will be documented in a supervision note.
The Intake Supervisor will review all admission charts, within 3 business days of the admission, to ensure that the personal history is completed as required. The Intake Counselor will be alerted of any deficient documentation, and it will be corrected within 24 hours of discovery.
The Counseling Staff is responsible for completing a psychosocial assessment, with all new admissions within 30 days of admission and for completion of case consultations every 6 months during the first month of admission and annually thereafter.
The Facility Director or Designee has developed a documentation tracker to track time-sensitive documentation to include psychosocial assessments and case consultations. The Facility Director or Designee will review the status of documentation in weekly supervision with the Clinical Supervisors and document the status in a supervision note.
The Clinical Supervisors have access to the documentation tracker and will review the status of all documents in weekly supervision with their assigned Counseling staff. Review of the status of documentation will be documented in a clinical supervision note by the Clinical Supervisors.
Clinical Supervisors will update the documentation trackers as they receive the required documentation, but minimally, once per week.
The Clinical Supervisors will hold a group clinical staff meeting where the Counseling staff will be retrained on all documentation requirements, including the psychosocial assessment and case consultations, as well as the timelines associated with the completion of these documents. Retraining will be documented in a group supervision note.
Supervision sessions documenting the status of documentation completion will begin 11/18/24.
A Case consultation for client #1 will be completed by 11/22/24
A quarterly review of charts is completed by the Data Analyst and will be reviewed during LPQI meetings.
The documentation tracker (this tracks SBCA completion and case consultation) will be monitored daily by Clinical Supervisors and is updated at least once a week with documentation occurring in supervision.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's January 2024 through September 2024 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility. on the following dates:
An incident, which occurred on February 27, 2024 and required police and/or ambulance personnel onsite, was documented in the logs; however, the incident was not reported to the Department until April 9, 2024. Additionally, a second incident, which occurred on May 20, 2024 and required police and/or ambulance personnel onsite, was documented in the logs; however, the incident was not reported to the Department until June 22, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director or Designee will provide retraining to staff responsible for completion of Unusual Incidents by 11/25/24. Retraining will include timeline submission to DDAP within 3 days of the incident.
All internal critical incident notifications will have a corresponding Unusual Incident reported completed in the DDAP Incident Reporting Portal within 2 business days of the incident by appropriate Management staff.
The Facility Director or Designee will submit a list and a brief description of all unusual incidents for the month to the Project Director who will then review the status at least once per month in supervision.
Review of monthly Unusual Incidents will be documented in a supervision note by the Project Director.
Any Unusual Incidents that are found to have not been submitted within the appropriate timeframe will be reported to DDAP within 24 hours of discovery and staff who were deficient in reporting will be again reminded of timelines.
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715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to a receiving narcotic treatment program for a transferring patient in one of one applicable patient record reviewed.
Client # 5 was admitted on June 14, 2024 and was transferred to another narcotic treatment program on August 19, 2024. There was no documentation in the client record of what materials were sent to the narcotic treatment program for the transferring patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff initiating transfers will be retrained on documents required to transfer an individual to an external facility by 11/18/24.
Effective 12/2/24, the staff facilitating this transfer to an external facility, will scan and upload the entire transfer packet into the client's electronic health record in order to show evidence of the documents that were sent to the identified facility. The supervisor will review client chart to ensure the transfer packet has been uploaded within their regularly scheduled supervision.
Ongoing monitoring of uploading transfer packets will be conducted through monthly internal chart audits completed by the Clinical Supervisors.
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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, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in three of three applicable patient records reviewed.
Patient # 2 was admitted on February 14, 2019 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on February 12, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient # 3 was admitted on September 29, 2009 and was still active at the time of the inspection. The annual evaluation of the patient's status was completed by the counselor on September 30, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient # 6 was admitted on February 1, 2022 and was discharged on September 5, 2024. The previous annual evaluation of the patient's status was completed by the counselor on April 6, 2023 and the next evaluation was due to be completed on April 6, 2024; however, it was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director is responsible for reviewing, dating, and signing the annual evaluations submitted by the Counseling Staff.
Currently, the programs' electronic health record does not allow for the annual evaluations to be routed to the Medical Director for review, dating, and signature.
The agency's Electronic Health Record Team has been notified of the need to ensure that the annual evaluations can be routed to the Medical Director.
The Electronic Health Record support team reports that the routing feature for the annual evaluations to begin going to the Medical Director will be implemented by 11/18/24.
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