INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 6-7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services, Inc - MedMark Treatment Centers Perryopolis 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 fire drill logs, the facility failed to document the exit route used for the fire drills conducted between May 2022 through February 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark Treatment Centers Perryopolis facility director will keep a log for each completed fire drill that will include the exit route used for each fire drill starting April 2023. The log will be kept in the health and safety binder. |
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.
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Observations
Based on a review of unusual incident reports, the facility failed to file a written report with DDAP within 3 business days following a client death.Client #9 was admitted on November 2, 2021 and passed away / discharged on June 14, 2022. There was no documentation that an unusual incident report was sent to DDAP.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark Treatment Centers Perryopolis facility director has a log-in for the POC website to enter unusual incidents in the electronic reporting system. Unusual incidents will be reported on the electronic reporting system to DDAP within 3 business days following the date of the incident. Client #9 incident (death) was submitted after the audit on the electronic monitoring system, 03/08/2023, to align with state regulation concerning unusual incident reporting. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in three of four client records.Client #1 was admitted on June 7, 2021 and discharged on October 20, 2022. There was no discharge summary documented in client record #1.Client #3 was admitted on June 13, 2022 and discharged on December 1, 2022. There was no discharge summary documented in client record #3.Client #8 was admitted on July 20, 2022 and discharged on December 6, 2022. There was no discharge summary documented in client record #8.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark Treatment Centers Perryopolis clinical treatment team will complete a discharge summary for each patient identified to be discharged commencing Friday 4/21/2023. Clinical team will keep track of documents due at discharge by following a discharge checklist. The supervisor will complete chart audits to ensure discharge documents are completed. The facility director reviewed this process with the clinical team and supervisor Monday, 4/17/2023, and documented the review in employees' record. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information, as per agency policy of 7 days post discharge, in one of three client records.Client #8 was admitted on July 20, 2020 and discharged on December 6, 2022. There was no follow up contact documented in client record #8.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark Treatment Centers Perryopolis clinical treatment team will complete a post discharge follow up at 7 days for each patient identified to be discharged commencing Friday 4/21/2023. Clinical team will keep track of documents due at discharge by following a discharge checklist. The supervisor will complete chart audits to ensure discharge documents are completed. The facility director reviewed this process with clinical team and supervisor Monday, 4/17/2023, and documented the review in employees' record. |