INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on July 25, 2023 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 of Pennsylvania, Inc. dba MedMark Treatment Centers Blairsville 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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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 client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in four out of ten client records reviewed.
Client #1 was admitted on January 10, 2023 and was still active at the time of the inspection. There was a release of information form for the emergency contact dated January 9, 2023 in the record however; the record did not have documentation that the client was offered a copy of the consent form.
Client #5 was admitted on October 24, 2022 and was still active at the time of the inspection. There was a release of information form for the emergency contact dated October 24, 2022 in the record however; the record did not have documentation that the client was offered a copy of the consent form.
Client #6 was admitted on June 26, 2023 and was still active at the time of the inspection. There were release of information forms for the emergency contact and the funding source dated June 26, 2023 in the record; however the record did not have documentation that the client was offered a copy of the consent forms.
Client #7 was admitted on October 3, 2022 and was discharged on March 9, 2023. There was a release of information form for the emergency contact dated October 3, 2022 in the record; however the record did not have documentation that the client was offered a copy of the consent form.
This is a repeat citation from the July 6 & 7, 2022 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will request a revision to the Legal Department of the Releases of Information that are currently in our software. Once revised, all Releases of Information will be updated in all patient files. The Facility Director will ensure that this is completed and ensure ongoing compliance when conducting random, monthly chart audits.
Until the revision to the releases is made, it will be documented in the patient's file that they were offered a copy of any release that they sign. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of February 19- 25, 2023, the patient census was 109. The facility was required to provide at least 10.9 physician hours. There were only 6 physician hours documented.
During the week of May 28-June 3, 2023, the patient census was 108. The facility was required to provide at least 10.8 physician hours. There were only 6 physician hours documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When our Physician cannot cover all hours required for this location in a week, the Facility Director will ensure that our backup Physician covers the deficient hours. The Facility Director will ensure ongoing compliance with Physician hours when running weekly census checks against Physician hours. |
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 facility failed to document an annual physical examination in one out of four applicable records.
Patient #2 was admitted on September 10, 2020 and was still active at the time of the inspection. The annual physical examination was due no later than September 10, 2022; however, was completed on September 13, 2022.
This is a repeat citation from the July 6 & 7, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All physical exams will be completed prior to the patient's anniversary date. The Facility Director discussed this with the medical staff and we have begun scheduling Physical exams prior to the anniversary date. The Facility Director will ensure ongoing compliance with this when conducting random, 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 evaluation within the regulatory timeframe in one out of four applicable records.
Patient #2 was admitted on September 10, 2020 and was still active at the time of the inspection. The annual evaluation was due no later than September 10, 2022; however, was completed on September 26, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All annual evaluations will be completed prior to the patient's anniversary date. We have begun revising our scheduling procedure to alert us to complete these evaluations a month before they are due. The Clinical Supervisors are overseeing the scheduling process and the Facility Director will ensure ongoing compliance when conducting random, monthly chart audits. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in two out of four applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #1 was admitted on January 10, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 10, 2023; however, it wasn ' t completed until February 27, 2023.
Client #7 was admitted on October 3, 2022 and discharged on March 9, 2023. A comprehensive treatment plan was due no later than November 3, 2022; however, it wasn ' t completed until November 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor held a training on Treatment Plan correction on 8/16/23 during a clinical team meeting. Time frames for completion of Treatment Plans was discussed. The Facility Director will ensure compliance with all clinical documentation, during random, monthly chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of ten records reviewed.
Client #3 was admitted on March 31, 2022 and was still active at the time of the inspection. A treatment plan update was completed on September 13, 2022, and the next update was due no later than November 13, 2022; however, the next update wasn ' t completed until November 15, 2022. The next update was due no later than January 15, 2023; however, the next update wasn ' t completed until February 22, 2023. The next update was due no later than April 22, 2023; however, the next update wasn ' t completed until April 24, 2023. The next update was due no later than June 24, 2023; however, it wasn ' t completed until June 30, 2023.
Client #5 was admitted on October 24, 2022 and was still active at the time of the inspection. A treatment plan was completed on November 2, 2022, and the next update was due no later than January 2, 2023; however, it wasn ' t completed until March 28, 2023. A treatment plan update was completed on May 24, 2023, and the next update was due no later than July 24, 2023; however, there was no documentation one was completed.
Client #7 was admitted on October 3, 2022 and discharged on March 9, 2023. A treatment plan was completed on November 22, 2022, and the next update was due no later than January 22, 2023; however, it wasn ' t completed until February 3, 2023.
Client #10 was admitted on July 30, 2017 and was still active at the time of the inspection. A treatment plan update was completed on February 10, 2023, and the next update was due no later than April 10, 2023; however, it wasn ' t completed until April 20, 2023.
This is a repeat citation from the July 6 & 7, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor held a training on Treatment Plan completion and timeframes on 8/16/23 during the clinical team meeting. The Facility Director will ensure ongoing compliance when conducting random, monthly chart audits. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations per the facility's policy and procedures, which states case consults occur at three months, six months, nine months, twelve months and annually thereafter in three out of nine applicable client records.
Client #1 was admitted on January 10, 2023 and was still active at the time of the inspection. A case consultation was due no later than April 10, 2023, however, there was no documentation that a one occurred.
Client #2 was admitted on admitted on September 10, 2020 and was still active at the time of the inspection. A case consultation was due no later than September 10, 2022; however, there was no documentation that one occurred.
Client #5 was admitted on October 24, 2022 and was still active at the time of the inspection. A case consultation was due no later than January 24, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor conducted a training to all clinical staff on 8/16/23 that included case consultation completion and time frames. All counselors attended the training and demonstrated an understanding of when case consultations are due during this clinical meeting. The Facility Director will ensure ongoing compliance with this when conducting random, monthly chart audits. |