INITIAL COMMENTS
|
This report is a result of an onsite complaint investigation conducted on May 2, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the complaint investigation, 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.
|
Plan of Correction
|
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. A portable space heater was observed, by DDAP staff, in the Clinical Supervisor ' s office.
The finding was disvussed with facility staff during the complaint investigation process.
|
Plan of Correction
The Facility Director has informed all staff that there are to be no space heaters in the building and that any existing ones need removed immediately. This was discussed during a staff meeting held on 5/20/25. The Facility Director will ensure compliance by regular monitoring of employee workspaces and offices. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had several unusual incidents that occurred on November 22, 2024, December 12, 2024, and January 19, 2025, all of which involved death of clients. Additionally, on April 18, 2025, the methadone pump was non-operative for the day. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident reports for this unusual incident.
These findings were reviewed with facility staff during the complaint investigation process.
|
Plan of Correction
The Facility Director reviewed the State Regulation on Incident Reporting, which included incidents that need reported to the state and timeframes for reporting. This review was done with all staff during a meeting on 5/20/25. The Facility Director will ensure ongoing compliance by reviewing every incident report submitted into Accreditation Now immediately upon completion and ensuring that documentation is sent immediately to the state and that confirmation of it being sent is kept on file with the incident report in the binder. |