INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 8 & 9, 2023, 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-Washington 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
|
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
There were two fire extinguishers located in the counselors ' hallways, and one fire extinguisher located in the old lobby area that were last inspected in June 2022.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
In accordance with 705.28, the Treatment Center Director will monitor fire extinguishers monthly and make sure they are operable. The Treatment Center Director will utilize safety inspection checklists twice a year. The Treatment Center Director will ensure that the building's fire extinguishers are being serviced yearly, including scheduling the inspection before the expiration date.
This citation was corrected on 8/30/23 when ABC Fire Extinguisher inspected the building's fire extinguishers. |
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 a review of the physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of July 23-29, 2023, the patient census was 280. The facility was required to provide at least 28 physician hours. There were only 6 physician hours documented.
This is a repeat citation from the July 27, 2022, January 11, 2023, and May 16, 2023 licensing inspections.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Treatment Center Director will review the Medical Director's schedule in relation to the current patient census to assure that the medical hours provided meet or exceed the state staffing requirements. A mid-level was hired in July and a second mid-level has been hired and will begin on September 25, 2023. The Treatment Center Director will monitor patient census continuously and increase provider hours as needed. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
|
Observations
Based on a review of patient records, the facility failed to ensure that prior to administration of an agent, that the narcotic treatment physician made a face-to-face determination of whether the patient was currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment and document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction in one of ten records reviewed.
Patient #4 was admitted on June 28, 2023 and was still active at the time of the inspection. Patient #4 was administered an agent on June 28, 2023, and the narcotic treatment physician did not document in the patient ' s record a one year history of addiction until June 30, 2023.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On the day of admission, physicians and mid-level providers at this facility will document their face-to-face evaluation in a service note, which will include the patient's history and opioid dependency for one year prior to admission. Upon completion of intake, Treatment Center Director and Counselor Supervisor will monitor that all intake documentation have been completed and signed. Treatment Center Director will monitor the physician and mid-level provider's intake note for every admission to confirm that the face-to-face evaluation is being conducted, including the documentation of the patient's 1 year of addiction. |
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 an average of one hour per month of group or individual psychotherapy during the third and fourth year of treatment in one out of two applicable records reviewed.
Patient # 9 was admitted on September 10, 2019 and was still active at the time of the inspection. There was no documentation that the patient received any psychotherapy sessions in July 2023.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Group sessions will be held monthly and patients will be able to utilize a group room to account for 1.5 hours of psychotherapy. Patients who have less than two years in treatment and are required 2.5 hours of psychotherapy a month, will attend at least one group session each month. Counselor Supervisor will monitor that Counselors are providing the appropriate amount of psychotherapy hours each month by using internal audit tools, excel spreadsheets for tracking purposes and checking counseling logs daily. Counselor Supervisor will review each Counselor's psychotherapy hours during monthly supervision and on an as needed basis. |
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.
|
Observations
Based on the review of patient records, the facility failed to document an annual physical examination by the narcotic treatment physician within the regulatory timeframe in one applicable record reviewed.
Patient #7 was admitted on June 17, 2021 and was still active at the time of the inspection. An annual physical was due no later than June 17, 2023; however, there was no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Designated medical staff will schedule each patient's annual physical prior to their anniversary date each year. Treatment center physician or mid-level will complete an annual physical with each patient and document the yearly evaluation accordingly. Medical providers will schedule patients accordingly by documenting on a printed calendar of appointment dates and times. Medical providers will provide Treatment Center Director the completed schedule for each month's appointments. If a patient is found to have missed an appointment, designated medical staff will be responsible for rescheduling with the patient. Upon completion of annual evaluation, medical providers will provide Treatment Center Director with documentation that the annual was completed. Treatment Center Director will monitor completed annuals by running weekly reports.
|
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on the review of patient records, the facility failed to document an annual evaluation of one applicable patient 's status by the patient 's counselor and reviewed, dated and signed by the medical director within the regulatory time frame.
Patient #7 was admitted on June 17, 2021 and was still active at the time of the inspection. An annual evaluation was due no later than June 17, 2023; however, it wasn't completed until July 10, 2023.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselors will run reports of all patient intake dates and complete annuals before the patient's anniversary date on a yearly basis. Counselors will place a hold on each patient in an appropriate time frame to ensure completion in a timely manner. Counselors will document all pertinent information, per state requirements. After the Counselor and patient have completed and signed the annual paperwork, the Medical Director will sign all necessary documents within the designated timeframe. The Medical Director will check the signing que on days when present to ensure that annual paperwork is signed. On a weekly basis, Treatment Center Director will monitor compliance by checking for completion of annual paperwork, as well as monitoring that all signatures are present. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in two applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #1 was admitted on June 9, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 9, 2023; however, it was not completed until July 18, 2023.
Client #4 was admitted on June 28, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 28, 2023; however, there was no documentation that the plan was completed at the time of the inspection.
This is a repeat citation from the May 16, 2023 licensing process.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
After a patient has been admitted to the program, Counselors will complete a comprehensive treatment plan within 30 days and every 60 days thereafter. The comprehensive treatment plan review will be updated with specific, individualized goals that are patient centered. Clinical staff will place holds on patients who have upcoming treatment plans due to ensure that they plan is completed in a timely manner. The Counselor Supervisor will monitor all comprehensive treatment plans on a monthly basis to ensure that they are completed by their due date. The Counselor Supervisor will review upcoming treatment plan deadlines during Supervision with Counselors. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on the review of client records, the facility failed to document case consultations within the guidelines established by the facility ' s policy and procedures manual in three out of four applicable client records. The facility's policy and procedures manual, states case consults occur at three months, six months, nine months, twelve months and annually thereafter.
Client #2 was admitted on December 1, 2022 and was discharged on June 27, 2023. A case consultation was due no later than March 1, 2023; however, there was no documentation that one occurred at the time of the inspection.
Client #7 was admitted on June 17, 2021 and was still active at the time of the inspection. A case consultation was due no later June 17, 2022; however, there was no documentation that one occurred at the time of the inspection.
Client #8 was admitted on December 20, 2022 and was still active at the time of the inspection. A case consultation was due no later than March 20, 2023: however, there was no documentation that one occurred at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Case consultations will be scheduled by Clinical staff and holds will be placed at the appropriate intervals for every 3 months of treatment for the first year and annually thereafter. These holds will alert Counselors of due dates. Counselor will consult with another staff member to discuss patient's case and document the discussion accordingly. Case consultations will be reviewed during monthly supervisions with the Counselor Supervisor. Counselor Supervisor will run weekly reports to monitor that case consultations are being completed by their due date. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on the review of client records, the facility failed to document an aftercare plan in four out of nine applicable client records. The facility's policy and procedures manual states that the aftercare plan is started at intake and completed prior to discharge.
Client #3 was admitted on October 22, 2022 and discharged on June 28, 2023. There was no documentation that an aftercare plan was completed.
Client #6 was admitted on September 16, 2016 and was still active at the time of the inspection. There was no documentation that an aftercare plan was started.
Client #7 was admitted on June 17, 2021 and was still active at the time of the inspection. There was no documentation that an aftercare plan was started.
Client #9 was admitted on September 10, 2019 and was still active at the time of the inspection. There was no documentation that an aftercare plan was started.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During admission, Clinical staff will start the patient's aftercare/transition plan with current information presented by the patient. Upon discharge from the program, a new aftercare/transition plan will be created and completed by the discharging Clinical staff member. This will be monitored by including it on the discharge checklist that will be provided to all Clinical staff and audited by Counselor Supervisor monthly. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record that included follow-up information within 30 days of discharge, per facility policy, in two out of three discharged records reviewed.
Client #3 was admitted on October 22, 2022 and discharged on June 28, 2023. Follow up information should have been documented by July 28, 2023; however, there was no follow up information documented at the time of the inspection.
Client #5 was admitted on June 22, 2023 and was discharged on July 7, 2023. Follow up information should have been documented by August 7, 2023; however, there was no follow up information documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselor Supervisor will run the discharge report at the end of each month. Counselor Supervisor will provide Counselors with the due date for their discharged patient's follow-up. Counselors will call the discharged patients to complete their follow-up and upload the documentation within 30 days of discharge. Counselor Supervisor will monitor monthly to ensure that the follow-ups are being completed in a timely manner. |
709.17(a)(1) 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:
(1) Failure to comply with a directive issued by the Department.
|
Observations
Based on an onsite annual licensing inspection conducted on August 8 & 9, 2023, the facility failed to comply with a directive issued by the Department. The facility requested an expansion into an additional suite in the building they are licensed in. The initial request was denied in January 2023 due to construction still being in progress in the suite they requested to expand to.
In February 2023, the facility failed to comply with the Department directive and began utilizing the additional suite for the dosing area and waiting room. A plan of correction was to be completed on July 11, 2023. On July 12, 2023, the facility was again informed the information needed submitted for the expansion to be approved. At the time of the inspection no documentation had been submitted to request the additional suite be inspected to utilize that space that is currently unlicensed.
This is a repeat citation from May 16, 2023.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
On September 7, 2023, the Regional Director of Operations put in a request for an address change due to the expansion and the submission has been completed. Currently awaiting approval from the Department. Going forward, if any expansion is found to be needed, this facility will follow the proper channels for approval before utilizing. |
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 and physical plant inspection, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to have physician services at least 1 hour per week onsite for every ten patients was approved for the January 11, 2023, and May 16, 2023, licensing inspections. This deficiency was found again during this licensing inspection.
A plan of correction for failing to develop individual treatment plans within the facility's policy time frame was cited during the May 16, 2023, licensing inspection. This deficiency was found again during this licensing inspection.
A plan of correction for failing to comply Department directive and began utilizing the additional suite for the dosing area and waiting room was approved for the May 16, 2023, licensing inspections. This deficiency was found again during this licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Regional Director of Operations, Treatment Center Director and Counselor Supervisor will work collaboratively to ensure that the plans of correction are being followed. Regional Director of Operations, Treatment Center Director and Counselor Supervisor will monitor these specific citations monthly to prevent occurrence in the future and make sure the plans of corrections are put in place and followed. |