INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29-30, 2022 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- Greensburg 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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705.28 (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
Based on a review of the August 27, 2021 through June 8, 2022 fire drill logs during the inspection, the facility failed to document the time, the amount of time it took for evacuation and exit route used.Fire drill logs August 27, 2021 and January 31, 2022 did not document the time.Fire drill logs August 27, 2021 through June 8, 2022 did not document exit route used.Fire drill logs August 27, 2021; January 31, 2022 and March 22, 2022 did not document amount of time it took for evacuation.These findings were reviewed by facility staff during the licensing process.
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Plan of Correction
A training will be provided to the Health and Safety Team on 7/29/22 that covers the state requirements for health and safety and drill conduction and documentation.
The Facility Director will ensure that when fire drills are being documented monthly, the following is included: amount of time it took to evacuate, the specific exit routes that were used and the time that the drill took place. The Facility Director will monitor compliance when reviewing the Health and Safety Binder. |
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 patient records, the facility failed to obtain a consent to release information form prior to releasing information in one out of eight records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.Patient #4 was admitted on September 25, 2020 and was discharged on March 16, 2022.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will provide a training to the Clinical Staff regarding the completion of Releases of Information, including all components of a valid release and accurate completion. This training will be held on Thursday, 7/21/22. Compliance will be monitored through random, monthly chart audits conducted by the Facility Director and Clinical Supervisor. |
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 patient records, the facility failed to obtain a completed informed and voluntary consent which included name of the person, agency, or organization to whom the disclosure is made in one out of eight records reviewed.Patient # 8 was admitted on March 9, 2022 and was still active at that the time of the inspection. A release signed and dated March 9, 2022 did not document to whom the disclosure was made.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide a training to the Clinical Staff regarding the completion of Releases of Information, including all components of a valid release and accurate completion. This training will be held on Thursday, 7/21/22. Compliance will be monitored through random, monthly chart audits conducted by the Facility Director and Clinical Supervisor. |
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 patient records, the facility failed to obtain a completed informed and voluntary consent which included specific information to be disclosed in one out of eight records reviewed.Patient # 7 was admitted on June 15, 2022 and was still active at that the time of the inspection. A release signed and dated June 15, 2022 was for an emergency contact.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide a training to the Clinical Staff regarding the completion of Releases of Information, including all components of a valid release and accurate completion. This training will be held on Thursday, 7/21/22. Compliance will be monitored through random, monthly chart audits conducted by the Facility Director and Clinical Supervisor. |
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 a review of patient records, the facility failed to obtain a completed informed and voluntary consent which included dated signature of a witness in one out of eight records reviewed.Patient # 7 was admitted on June 15, 2022 and was still active at that the time of the inspection. A release signed and dated June 15, 2022 was for an emergency contact.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide a training to the Clinical Staff regarding the completion of Releases of Information, including all components of a valid release and accurate completion. This training will be held on Thursday, 7/21/22. Compliance will be monitored through random, monthly chart audits conducted by the Facility Director and Clinical Supervisor. |
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 a review of the patient records, the facility failed to document that a copy of a patient consent shall be offered to the patient and a copy maintained in the patient record in four out of eight patient records reviewed. Patient #2 was admitted on April 20, 2022 and was still active at the time of the inspection. A release of information form for an emergency contact dated April 20, 2022 did not have documentation that the patient was offered a copy of the consent form. Patient #3 was admitted on August 11, 2021 and was still active at the time of the inspection. A release of information form for an emergency contact dated August 11, 2021 did not have documentation that the patient was offered a copy of the consent form. Patient #6 was admitted on December 7, 2018 and was still active at the time of the inspection. A release of information form for a medical provider dated September 27, 2021 did not have documentation that the patient was offered a copy of the consent form. Patient #7 was admitted on June 15, 2022 and was still active at the time of the inspection. A release of information form for an emergency contact dated June 15, 2022 did not have documentation that the patient was offered a copy of the consent form. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director has submitted this citation to our legal department to have a section added that reads "patient was offered a copy" and "yes or no". When the release is revised, all staff will be trained on the new form. Then, all patient records will be updated to have the revised releases added to each patient record. The Facility Director and Clinical Supervisor will monitor for compliance when conducting random, monthly chart audits. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician did not prescribe an initial dose to exceed 30 milligrams in one out of four applicable records reviewed. Patient #3 was admitted on August 11, 2021 and was discharged on March 17, 2022. Her initial dose on August 11, 2021 was 35mg.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
This citation and the maximum, initial dose allowed has been addressed individually with the prescribing Physician by the Facility Director and Medical Director. The Facility Director will monitor for ongoing compliance when auditing new intake files. |
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 patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of five applicable records reviewed.Patient #4 was admitted on September 25, 2020 and was still active at the time of the inspection. In December 2021, the patient only received 1.8 hours individual psychotherapy sessions and no group sessions. In January 2022, the patient received .58 hours of individual psychotherapy. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A review of minimum counseling requirements, documentation of sessions and documentation of "no show" sessions has been reviewed with the clinical staff by the Clinical Supervisor. This was held on 7/13/22. The Clinical Supervisors and Facility Director will monitor ongoing compliance with this through ongoing, monthly chart audits. |
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 document an annual clinical evaluation within the regulatory timeframe in one out of three applicable records. Patient #6 was admitted on December 7, 2018 and was still active at the time of the inspection. The annual clinical evaluation was due on December 7, 2021 and as of the date of this inspection has not been completed.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director has implemented a system to be put into place to prompt an alert of the patient's chart when their annual clinical paperwork is due. This alert will be added upon patient intake to ensure patients will not be missed. The Facility Director and Clinical Supervisor will make this part of our ongoing auditing process when reviewing new intake charts. |