INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 27-28, 2024 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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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 facility fire drill log for the months of July 2023 through August 2024, the facility failed to maintain a written fire drill record including documentation of whether the fire alarm or smoke detector was operative in fourteen of fourteen logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For September, the smoke detectors have all been tested by the Supervisor and are fully functional. Moving forward, all smoke detectors will be tested monthly when the monthly drill is conducted. The results of the testing will be documented with the drill. The Facility Director will ensure ongoing compliance when auditing the health and safety binder. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of July 2023 through August 2024, the facility failed to conduct fire drills at different times of the day in fourteen of fourteen logs. All the fire drills were conducted between 11:02am, and 12:17pm
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Supervisor will ensure that fire drills are conducted at different times each month during business operations, beginning with this month's drill. The Facility Director will ensure ongoing compliance when auditing the Health and Safety Binder and reviewing the times that the drills are being held. |
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 the review of the facility's fire drill log for the months of August 2023 through June 2024, the facility failed to set off a fire alarm or smoke detector during each fire drill in fourteen of fourteen logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Clinical Supervisor will ensure that the smoke detectors are set off during each monthly fire drill. The Facility Director will ensure compliance by making sure that this is documented and will review during regular audits of the Health and Safety Binder. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on applicable patient records reviewed, the facility failed to provide documentation of a random drug-screening urinalysis for each patient and at least monthly in one of seven records.
Patient #3 was admitted on December 14, 2023 and was still active at the time of the inspection. A random drug-screening urinalysis was not completed for the month of July 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Nurse will be responsible for running a report in SAMMS that shows all of the patients who haven't had a urine test for the month. This will be done during the last week of the month. We will check this list in SAMMS to make sure that all of these patients are scheduled for a test and if not, we will manually schedule them. The Treatment Center Director will ensure compliance when conducting random, monthly chart audits. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in four of four records.
Client #2 was admitted on June 20, 2024 and was still active at the time of the inspection. The treatment plan was dated July 18, 2024.
Client #3 was admitted on December 14, 2023 and was still active at the time of the inspection. The treatment plan was dated December 14, 2023.
Client #4 was admitted on January 8, 2024 and was still active at the time of the inspection. The treatment plan was dated January 8, 2024.
Client #7 was admitted on March 4, 2024 and was still active at the time of the inspection. The treatment plan was dated March 4, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A training will be conducted to the clinical staff on 9/26/24 by the Counselor Supervisor. This training will review treatment planning and focus specifically on "support services". Ongoing compliance will be monitored by the Facility Director when conducting 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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of six applicable records.
Client #1 was admitted on May 6, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 17, 2024. A treatment and rehabilitation plan update was due no later than July 17, 2024, but was not completed until July 19, 2024.
Client #5 was admitted on July 24, 2023 and was discharged on January 12, 2024. A treatment and rehabilitation plan was developed on October 26, 2023. A treatment and rehabilitation plan update was due no later than December 26, 2023, but was not completed until December 27, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 25, 2023 and July 6-7, 2022 annual licensing inspections.
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Plan of Correction
A training for the Clinical Staff will be held on 9/26/24 by the Clinical Supervisor regarding Treatment Planning. This training will include time frames for completion of Treatment Plans. The Facility Director will ensure ongoing compliance with this when completing random, monthly chart audits. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates was submitted and approved by the Department for the July 25, 2023 and July 6-7, 2022 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the August 27-28, 2024 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
After the Clinical Supervisor facilitates a training for the clinical staff on 9/26/24 that will focus on all components of treatment planning and time frames for completion of treatment plans, compliance will be monitored by the Facility Director. The Facility Director conducts random, monthly chart audits to monitor compliance. The Facility Director will increase the volume of these audits and will address individually those who are struggling with compliance. This may result in disciplinary action for the employee in the form of a "performance Improvement Plan". |