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 2, an abbreviated on-site inspection, conducted on November 9-10, 2020 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Med Mark Treatment Centers of Pennsylvania d/b/a Med Mark Treatment Centers Coun 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on the administrative review for the annual inspection on November 9-10, 2020, the facility failed to document by written signature that the project director prepared, and annually updated the manual.
There was no documentation that the project director prepared and annually updated the manual for 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When the Administrative policies are reviewed and revised each year, a signature sheet will be added to the manual that shows acknowledgment from our Project Director that the revisions/updates were approved. The Facility Director will monitor compliance annually by ensuring that this signature sheet is included each year when the manual is distributed. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of thirteen client records reviewed.
Client # 8 was admitted to treatment on June 20, 2020. The client record contained documentation of a letter sent to a probation officer on July 15, 2020. There was no consent to release information in the client record.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
This consent was found in the patient's broken down file, that was not provided during the audit. The Facility Director will ensure that when breaking down patient files to save space in the file, all pertinent, current information be included in the file that is in with active charts. Compliance will be monitored during random, monthly chart audits by the Facility Director. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to document that clients were provided written acknowledgement by clients that they have been notified of the right that no client may be deprived of a civil right solely by reason of treatment in fourteen of fourteen client records.
Client records # 1, 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 did not contain written acknowledgement by clients that they have been notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When the annual revisions to the policy manual take place, the Patient Rights will be revised to add that "no client may be deprived of a civil right solely by reason of treatment". The Facility Director will ensure compliance by reviewing the policy manual to make sure this was added when it is distributed for 2021. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records, the facility failed to document that clients were provided written acknowledgement that they have been notified of the right that they may not be discriminated against based on creed, sex, color or national origin, that in fourteen of fourteen client records.
Client records # 1, 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 did not contain written acknowledgement by clients that they have been notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When the annual revisions to the policy manual take place, the Patient Rights will be revised to add that "patients will be notified of the right that they may not be discriminated against based on creed, sex, color or national origin". The Facility Director will ensure compliance by reviewing the policy manual to make sure this was added when it is distributed for 2021. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the facility failed to document that clients were provided written acknowledgement that they have been notified of the right that reasons for removing sections shall be documented in the record in fourteen of fourteen client records.
Client records # 1, 2, 3, 4, 7, 8, 9,10, 11, 12, 13, 14, 15 and 16 did not contain written acknowledgement by clients that they have been notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When the annual revisions to the policy manual take place, the Patient Rights will be revised to add that "patients will be notified of the right that reasons for removing sections shall be documented in the record". The Facility Director will ensure compliance by reviewing the policy manual to make sure this was added when it is distributed for 2021. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client records, the facility failed to document that clients were provided written acknowledgement that they have been notified of the right that they had the right to appeal a decision limiting access to their records to the director in fourteen of fourteen client records.
Client records # 1, 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 did not contain written acknowledgement by clients that they have been notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When the annual revisions to the policy manual take place, the Patient Rights will be revised to add that "patients will be notified of the right to appeal a decision limiting access to their records to the director". The Facility Director will ensure compliance by reviewing the policy manual to make sure this was added when it is distributed for 2021. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to document that it notified the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of three client records.
Client # 12 was admitted on January 10, 2020 and involuntarily discharged on July 30, 2020. There was no documentation that the client was notified, in writing, of the decision to terminate the client's treatment.
Client # 13 was admitted on January 7, 2020 and involuntarily discharged on May 7, 2020. There was no documentation that the client was notified, in writing, of the decision to terminate the client's treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical and Clinical staff were trained on the process of involuntarily terminating a patient on 12/2/20. Compliance will be monitored by the Clinical Supervisors during random, monthly chart audits. |
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
The facility failed to complete random monthly urinalysis is one of ten patient records.
Patient # 5 was admitted on November 5, 2012 and discharged on March 5, 2020. There was no documentation of a urinalysis for November 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A report will be run prior to the last week of each month to ensure that any patient who is not scheduled to have a random, monthly urine screen will be scheduled to have a test done. Compliance will be monitored by the Facility Director during monthly, random chart audits. |
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 the review of patient records, the facility failed to document an annual physical examination in one of three patient records.
Patient # 5 was admitted on November 5, 2012 and discharged on March 5, 2020. There was no documentation that an annual physical examination was completed in 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medical staff will place a "hold" on every patient each year to ensure they are prompted to schedule a physical examination for every patient at their annual anniversary. The Facility Director will ensure compliance with this during random, monthly chart audits. |