INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 26-27, 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 - 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on August 2, 2023 and was due to have the communicable disease trainings no later than August 2, 2024. There was no documentation in the personnel file of the completion of TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Employee #4 attended the TB/STD training on 9/12/2024. In the future, The Facility Director will ensure that all new Clinical Employees schedule their trainings closer to their start date, so that there are no issues with trainings being full. The Facility Director will ensure ongoing compliance with this when auditing employee records monthly. |
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.
|
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.
|
Plan of Correction
The Facility Director will coordinate fire drills with Excela Health, located in our building. They have access to the whole building's fire alarm system. We will document whether or not the fire alarm was operative, based on these coordinated drills. The Facility Director will monitor ongoing compliance with this when auditing the Health and Safety Binder. |
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
|
Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services at least one hour per week onsite for every ten patients for three of thirteen weeks.
During the week of March 23, 2024 through March 29, 2024, the facility's census was 382. The facility was required to provide 38.2 hours of onsite physician services; however, they provided 30 hours.
During the week of April 13, 2024 through April 19, 2024, the facility's census was 384. The facility was required to provide 38.4 hours of onsite physician services; however, they provided 38 hours.
During the week of August 5, 2024 through August 10, 2024, the facility's census was 400. The facility was required to provide 40 hours of onsite physician services; however, they provided 37 hours.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
We will be proactive when a Physician needs to take time off and we foresee being deficient in medical hours. When there is a holiday or a provider needs to take time off, we will ensure coverage by having another Physician cover the hours for the week. The Facility Director will ensure adequate coverage by reviewing the patient census with the Physician hours each week. |
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.
|
Observations
Based on the review of patient records, the facility failed to complete random urinalysis at least monthly in one of seven patient records.
Patient #2 was admitted on June 26, 2014 and was still active at the time of the inspection. There was no documentation of a urinalysis done in May 2024.
This finding was reviewed with facility staff during the licensing inspection.
|
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. |
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.
|
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 two applicable records.
Patient #1 was admitted on September 13, 2023 and was still active at the time of the inspection. In October 2023, the patient received one hour of psychotherapy. In November 2023, the patient received two hours and fifteen minutes of psychotherapy. In December 2023, the patient received two hours of psychotherapy. In January 2024, the patient received one hour of psychotherapy. In February 2024, the patient received two hours of psychotherapy. In March 2024, the patient received one hour of psychotherapy. In May 2024, the patient received two hours of psychotherapy. In June 2024, the patient received two hours of psychotherapy. In July 2024, the patient received one hour and forty-five minutes of psychotherapy.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 27, 2023 and June 30, 2022 licensing inspections
|
Plan of Correction
During a clinical meeting to be held on 9/25/24, the Clinical Supervisor will review counseling requirements for each phase that a patient is in. The Facility Director will monitor compliance during random, monthly chart audits. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to provide patients with one hour per month of therapy during the third and fourth year of treatment in one out of two applicable records.
Patient #4 was admitted on July 27, 2020 and was still active at the time of the inspection. In March 2024, the patient received fifteen minutes of psychotherapy. In May 2024, the patient received thirty minutes of psychotherapy.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During a clinical meeting to be held on 9/25/24, the Clinical Supervisor will review counseling requirements for each phase that a patient is in. The Facility Director will monitor compliance 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.
|
Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of seven applicable records.
Client #1 was admitted on September 13, 2024 and was still active at the time of the inspection. A treatment plan update was completed on June 10, 2024 and the next update was due no later than August 10, 2024; however, the next update was completed on August 20, 2024.
Client #6 was admitted on December 7, 2021 and was discharged on May 8, 2024. A treatment plan update was completed on March 4, 2024 and the next update was due no later than May 4, 2024; however, it was completed on May 8, 2024.
Client #8 was admitted on November 29, 2018 and discharged on July 9, 2024. A treatment plan update was completed on May 7, 2024 and the next update was due no later than July 7, 2024; however, it was completed on July 9, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 27, 2023 licensing inspection.
|
Plan of Correction
A training for the Clinical Staff will be held on 9/25/24 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.
|
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 providing 2.5 hours of psychotherapy per month during the patient's first two years of treatment was submitted and approved by the Department for the July 27, 2023 and June 30, 2022 licensing inspections. Psychotherapy hours were again found to be a deficiency in the August 26-27, 2024 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Clinical Staff will receive training on 9/25/24 on requirements for psychotherapy based on the phase that the patient is in. Following the training, the Facility Director will monitor compliance with this by increasing the volume of files that are audited randomly each month. Any issues will be addressed individually with the counselor and progressive discipline may be initiated. |