INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 26-27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MedMark Treatment Centers Washington 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility failed to document a sufficient number of CPR/First Aid certifications.
CPR and first aid documentation was requested while the licensing specialist was onsite. There was no documentation of CPR/First Aid certification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will ensure that Employee #1 and a few other staff acquire CPR/First Aid Certification. Copies of certification will stay on site.
Treatment Center Director will ensure a calandar reminder is completed for Employee #1 and those staff who become certified, to ensure recertifications are completed prior to expiration date.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate each bathroom by exhaust fan or window.
The physical plant inspection was conducted on August 26, 2021 at approximately 3:45 PM. At the time of the physical plant inspection, the fan in one of the staff bathrooms was inoperable. There is no window present.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will coordinate with building maintenance to either have exhaust fan repaired or replaced.
Treatment Center Director will ensure that fans are always assessed during physical inspections. |
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
Based on a review of personnel and training records, the facility failed to document that each staff was instructed in the use of fire extinguishers upon staff employment in one of one record.
The project had a change of ownership in December 2020. Only one of the clinical staff has been hired since the change of ownership. Employee #1 was hired on March 3, 2021. There was no documentation of fire extinguisher training in staff record #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will coordinate a training, or have a third party training on the use of fire extinguishers. Proof of training will be kept on file and will continue going forward to remain in compliance.
Employee # 1 will receive and complete fire extinguisher training. |
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.
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Observations
Based on a review of fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
The fire drill logs were reviewed for the period of August 2020 - August 2021. There were no fire drills documented for the months of December 2020 and January, February, March 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director has already started ensuring that fire drills will be conducted unannounced at least once monthly. Treatment Center Director will ensure that all documentation reflects properly. Proof of drill completions will be kept in a safety binder on site at the facility safety binder |
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
Based on a review of personnel and training records, the facility failed to document that each staff was instructed in emergency training upon staff employment in one of one record.
The project had a change of ownership in December 2020. Only one of the clinical staff has been hired since the change of ownership. Employee #1 was hired on March 3, 2021. There was no documentation of emergency training in staff record #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will immediately ensure that all new employees moving forward will receive Emergency Training. This will be documented and kept on file at the facility.
Employee # 1 will receive Emergency Training. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to document that the fire alarm or smoke detector was set of during each fire drill.
The fire drill logs were reviewed for the time period of August 2020 - August 2021. The fire drills conducted during the months of April, May, June and July 2021 did not include documentation that the fire alarm or smoke detector was sent off, it was documented that a bell/buzzer or an intercom was utilized instead.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will ensure that all fire drills moving forward will entail the usage of a fire alarm or smoke detector. This will be documented in the fire drill log and kept in the safety binder at the facility. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of medication storage inspection logs, the facility failed to document inspections of the medication storage area at least quarterly.
The period reviewed was August 2020 - August 2021. During that time, medication storage inspections were conducted on August 21 and November 18, 2020. There were no inspections of the medication storage area documented since November 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will educate and ensure that quarterly medication storage inspection logs are completed and documented moving forward. Documentation will be kept in dosing/nurses station at the facility. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of administrative documentation, the facility failed to file an unusual incident report with DDAP within 3 business days following a client death.
Client #7 was admitted on November 6, 2018 and discharged as a result of his death on May 17, 2021. There was no doucmentation that an unusual incident report was sent to DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will immediately correspond to all staff via staff meeting and email to ensure that moving forward all patient deaths are properly filed with DDAP to remain in compliance.
Treatment Center Director will also update all staff each month as continued training to avoid further failed reports with regards to a patient death. |