INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on June 25, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Med Mark 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.
Employee # 10 was hired as a counselor on July 22, 2019. The employee meets the educational requirements but does not have one year of required clinical experience. Employee had 0 months of qualifying experience at the time of hire. The employee has only 11 months of experience as of this inspection.
This is a repeat citation as the employee's personnel record was reviewed during the July 29-31, 2019 licensing inspection. The employee did not have the required experience at that time.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will ensure that all incoming employees have a thorough review of transcripts and resumes prior to start to ensure that they meet the minimum qualifications of a counselor position. The Facility Director will review this information and will ensure compliance with this during ongoing audits of employee files. |
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
The facility failed to ensure that each counselor completed at least 25 clock hours of annual training in one of two personnel records.
Employee # 6 was hired as a counselor on April 16, 2018. The employee had only 18.75 documented training hours for the January to December 2019 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of training requirements that are mandatory for each position per calendar year has been reviewed with staff during a meeting held on 7/1/20. The Facility Director will ensure compliance with training hours by reviewing training records each quarter and updating staff each quarter with the amount of training they have completed and have on file. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to comply with the client/counselor ratio of 35/1 active clients.
Based on the review of the Staffing Requirement Facility Summary Report, employee # 8 had an active client/counselor ratio of 39/1.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The additional patients have been removed from employee #8's caseload and distributed to another counselor who had space to add. The Facility Director will ensure ongoing compliance by checking caseloads on a weekly basis to ensure that counselors do not exceed the 35:1 ratio of active patients. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to develop a written procedure that was compliant with Federal and State confidentiality regulations based on a review of the facility's policy.
The facility's confidentiality policy and procedure stated that without the consent of the client the facility could release information to the following: judges who have imposed sentence on a client where such sentence is conditioned upon the client entering a project, probation or parole officers who have assigned responsibility to clients in treatment if the probation or parole is conditioned upon his being in treatment and judges who have assigned a client to a project under pre-sentence, conditional release program. This is in violation of Federal and State confidentiality regulations 42 CFR, Part II, Subpart C and 71 P.S.1690.108 (b) which requires written client consent.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark's Confidentiality policy will be revised to align with Federal and State regulations 42 CFR, Part II, subpart C and 71 P.S.1690.108 (B) which requires written client consent. Ongoing compliance will be monitored by the Facility Director when annual reviews of MedMark's Policy and Procedure manual takes place. |