INITIAL COMMENTS
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This report is a result of an on-site licensure follow up inspection and methadone monitoring inspection conducted on March 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-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:
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Plan of Correction
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in four out of fourteen client records reviewed.
Client #11 was admitted on January 9, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for an emergency contact dated January 9, 2024 was offered to the client.
Client #12 was admitted on November 3, 2023 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for an emergency contact dated November 3, 2023 was offered to the client.
Client #13 was admitted on December 11, 2023 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for an emergency contact dated December 11, 2023 was offered to the client.
Client #14 was admitted on February 14, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source, emergency contact and a medical provider dated February 19, 2024 were offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counseling staff will offer a copy of release of information to all patients when signing the document. Counseling staff will notate in the note section whether the patient accepted or declined a copy of release of information. Treatment Center Director and Counselor Supervisor will monitor releases and perform audits to ensure that all patients are being offered a copy of the release and whether it was accepted or declined. Treatment Center Director and Counselor Supervisor will perform an audit of active patient releases to ensure that the consent states whether the patient accepted or declined a copy of release. All releases will be updated with the patient as needed. Treatment Center Director and Counselor Supervisor will continue to provide ongoing documentation training to Counseling staff. |
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
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Observations
Based on 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 October 15-21, 2023, the patient census was 269. The facility was required to provide at least 26.9 physician hours. There were only 21 physician hours documented.
During the week of November 19-25, 2023, the patient census was 273. The facility was required to provide at least 27.3 physician hours. There were only 26.75 physician hours documented.
During the week of December 24-30, 2023, the patient census was 274. The facility was required to provide at least 27.4 physician hours. There were only 24 physician hours documented.
During the week of December 31, 2023- January 6, 2024, the patient census was 274. The facility was required to provide at least 27.4 physician hours. There were only 27 physician hours documented.
This is a repeat citation from the July 27, 2022, January 11, 2023, May 16, 2023 and August 9, 2023 licensing inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will review provider hours in relation to the current patient census on an ongoing basis and increase provider hours as needed. Treatment Center Director will ensure that the facility provides one hour of physician time for every ten patients. Treatment Center Director will monitor continuously to assure the provider hours are in compliance with state regulations. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician.
During the week of October 15-21, 2023, the patient census was 269. The physician was required to provide one-third of the 26.9 hours, which equals to 8.8 hours. There were no documented physician hours.
During the week of December 31, 2023- January 6, 2024, the patient census was 274. The physician was required to provide one-third of the 27.4 hours, which equals to 9 hours. There were no documented physician hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will monitor physician hours on a consistent basis to ensure that the physician is onsite for one-third of the provider time required. Treatment Center Director will monitor patient census and increase physician hours as needed. |
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.
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Observations
Based on a review of patient records, the facility failed to provide patients with an average of two and half hours of psychotherapy per month during the patients first two years, one hour which shall be individual psychotherapy in one out of seven applicable records reviewed.
Patient #11 was admitted on January 9, 2024 and still active at the time of the inspection. There was no documentation that the patient received any psychotherapy sessions in the month of February 2024.
This is a repeat citation from the July 27, 2022, January 11, 2023, May 16, 2023 and August 9, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director and Counselor Supervisor will perform audit checks on a continuous basis to assure that all patients under 2 years of treatment are receiving 2.5 hours of psychotherapy each month, one hour being individual psychotherapy. Clinical staff to provide group psychotherapy to patients on a monthly basis. Clinical staff will schedule patients for the required psychotherapy time and document missed appointments. Clinical staff to follow-up with patients and reschedule missed appointments. Clinical staff will audit caseloads on a weekly basis and schedule with patients for the required time. Counselor Supervisor will monitor psychotherapy hours on an ongoing basis and discuss with Clinical staff during supervision. |
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.
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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 three out of four applicable records reviewed.
Patient #6 was admitted to the facility on November 29, 2022 and was still active at the time of the inspection. There was no documentation that the patient received any psychotherapy sessions in February 2024.
Patient #7 was admitted to the facility on October 28, 2022 and was still active at the time of the inspection. There is no documentation that the patient received any psychotherapy in the months of November and December 2023 and January and February 2024.
Patient #10 was admitted to the facility on October 4, 2023 and was still active at the time of the inspection. There is no documentation that the patient received any psychotherapy in the months of December 2023, January and February 2023.
This is a repeat citation from the August 9, 2023 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselors will schedule patients in their third and fourth year for 1 hour of individual psychotherapy every month. Counselors will document missed appointments and reschedule with the patient. Counselors will complete 1 hour of psychotherapy before the end of the month. Counselor Supervisor will print the patients without counseling report and distribute to Counselors weekly. Counselor Supervisor and Treatment Center Director will perform chart audits on a regular basis and discuss with Counselors during Supervision. |
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 the results of annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in four out of six applicable records reviewed.
Patient #5 was admitted on December 18, 2018 and was still active at the time of the inspection. An annual physical was due no later than December 18, 2023; however, it was not completed until December 28, 2023.
Patient #6 was admitted on November 29, 2022 and was still active at the time of the inspection. An annual physical was due no later than November 29, 2023; however, there is no documentation that one was completed.
Patient #8 was admitted on December 20, 2022 and was still active at the time of the inspection. An annual physical was due no later than December 20, 2023; however, there was no documentation that one was completed.
Patient #9 was admitted November 29, 2022 and was still active at the time of the inspection. An annual physical was due no later than November 29, 2023; however, there was no documentation that one was completed.
This is a repeat citation from the August 9, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Medical providers will review report that lists all patient's intake dates. Providers will place a hold 2 months prior to annual date to ensure compliance of all annual requirements. Medical providers will document missed appointments and reschedule patients prior to due date.
Treatment Center Director and Medical Director will monitor patient charts regularly to ensure completion in a timely manner. |
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.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation of each patient 's status to be completed by the patient 's counselor and be reviewed, dated and signed by the medical director in five out of six applicable records reviewed.
Patient #5 was admitted on December 18, 2018 and is still active at the time of the inspection. An annual evaluation was due no later than December 16, 2022; however, it was not completed until January 4, 2024 and was not reviewed, dated and signed by the medical director.
Patient #6 was admitted on November 29, 2022 and was still active at the time of the inspection. An annual evaluation was due no later than November 29, 2023; however, it was not completed until January 26, 2024 and was not reviewed, dated and signed by the medical director.
Patient #7 was admitted on October 28, 2022 and was still active at the time of the inspection. An annual evaluation was completed on September 29, 2023; however, there is no documentation that the evaluation was reviewed, dated and signed by the medical director.
Patient #8 was admitted on December 20, 2022 and was still active at the time of the inspection. An annual evaluation was due no later than December 20, 2023; however, there was no documentation that one was completed.
Patient #9 was admitted on November 29, 2022 and was still active at the time of the inspection. An annual evaluation was due no later than November 29, 2023; however, there is no documentation that one was completed.
This is a repeat citation from the August 9, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon completion of Counselor annual, Counselor will inform Medical Director of completed paperwork. Medical Director will review, sign and date annual paperwork.
Counselors will submit annual checklist to Counselor Supervisor for review upon completion. Treatment Center Director will monitor annual documentation by performing chart audits of completed annual documentation to ensure that Medical Director's signature is present. Treatment Center Director will provide ongoing training to Medical Director. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of patient records, the facility failed to file a written Unusual Incident Report with the Department within 48 hours following an unusual incident.
The facility received notification on February 14, 2024, that an active patient was deceased. There was no documentation that an Unusual Incident was filed with the Department.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director filed a written Unusual Incident Report to the department on 4/5/24. This deficiency was corrected on this date. When the Treatment Center Director becomes aware of an unusual incident, Treatment Center Director will file Unusual Incident Report to the department within the 48 hour timeframe. Treatment Center Director will continue to monitor unusual incidents and file reports in a timely manner. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to have intake procedures that included documentation of a psychosocial evaluation in two out of six applicable records.
Client #11 was admitted on January 9, 2024 and was still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed.
Client #14 was admitted on February 14, 2024 and was still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a patient is admitted to the program, Counselors will complete ASI within 5 days of intake. Upon completion of intake, Counselors will provide intake checklist to Counselor Supervisor for review. Counselor Supervisor will audit each intake to ensure that ASI is completed within the appropriate timeframe. Treatment Center Director will monitor for completion. Treatment Center Director and Counselor Supervisor will provide ongoing training to Counseling staff. |
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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan was developed with the client within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #10 was admitted on October 4, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 4, 2023; however, it was not completed until November 17, 2023.
Client #12 was admitted on November 3, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 30, 2023; however, there is no documentation that the treatment plan was developed with the client.
Client #13 was admitted on December 11, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 11, 2024; however, it was not completed until January 23, 2024.
Client # 14 was admitted on February 14, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 14, 2024; however, there is no documentation that the plan was completed at the time of the inspection.
This is a repeat citation from the May 16, 2023 and August 9, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling staff will complete the comprehensive treatment plan with the patient within 30 days of intake. Counselors will schedule with the patient to complete comprehensive treatment plans of new admissions and place a hold in the patient's chart to ensure timeliness of documentation. Counselor Supervisor will monitor the intakes and track completion dates by utilizing EMR reports. Counselor Supervisor will audit charts on an ongoing basis to be sure that comprehensive treatment plans are completed by the due date. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in two out of six applicable client records reviewed.
Client #12 was admitted on November 3, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 30, 2023 that did not include documentation of the type or frequency of treatment and rehabilitation services.
Client #13 was admitted on December 11, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 23, 2024 that did not include documentation of the type or frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When completing treatment plans with the patients every 60 days, Counselors will include the type and frequency for every treatment plan. Counselors will track treatment plan due dates and be sure to complete with the patient in the appropriate time frame. When signing the treatment plans, Counselor Supervisor will monitor treatment plans and perform chart reviews on completed plans to make sure that type and frequency is indicated on the plan and that treatment plans are being submitted before due date. Counselor Supervisor will notify Counseling staff if revision is needed. Counselor Supervisor and Treatment Center Director will provide ongoing documentation training to the Counseling staff. |
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.
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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 eight out of thirteen 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 #4 was admitted on October 30, 2023 and was discharged on February 16, 2024. A case consultation was due no later than January 30, 2024; however, there was no documentation that one occurred.
Client #5 was admitted on December 18, 2018 and was still active at the time of the inspection. A case consultation was due no later than December 18, 2023; however, there was no documentation that one occurred.
Client #7 was admitted on October 28, 2022 and was still active at the time of the inspection. A case consultation was due no later than October 28, 2023; however, there was no documentation that one occurred.
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 December 20, 2023; however, there was no documentation that one occurred.
Client #9 was admitted on November 29, 2022 and was still active at the time of the inspection. A case consultation was due no later than November 29, 2023; however, there was no documentation that one occurred.
Client #10 was admitted to October 4, 2023 and was still active at the time of the inspection. A case consultation was due no later than January 4, 2024; however, there was no documentation that one occurred.
Client #12 was admitted on November 3, 2023 and was still active at the time of the inspection. A case consultation was due no later than February 3, 2024; however, there was no documentation that one occurred.
Client #13 was admitted on December 11, 2023 and was still active at the time of the inspection. A case consultation was due no later than March 11, 2023; however, there was no documentation that one occurred.
This is a repeat citation from the August 9, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon intake, Counselors will track case consultations by placing holds in patient's charts at 3 months, 6 months, 9 months, 1 year and annually thereafter. Counselor Supervisor and Counselor will discuss case consultations during Supervision and Counselor will complete case consultation after discussion. Counselor Supervisor will track admissions and sign off on case consultations as they are completed. Counselor Supervisor will audit patient charts to ensure that case consultations are completed in the appropriate time frame. Counselor Supervisor will provide documentation training to Counseling staff on an ongoing basis. |
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 provide a complete client record, which is to include follow-up information per the facility ' s policy and procedure manual within thirty days of discharge in one out of two applicable discharged records reviewed.
Client #1 was admitted on April 26, 2021 and discharged on January 30, 2024. There was no documentation that a follow up occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor Supervisor will print the previous month's discharges and provide a copy to the Counseling staff, which includes each patient's discharge date. Counseling staff will make an attempt to reach patients by phone and complete the post discharge follow-up within 30 days. Upon completion, Counseling staff will upload document in the patient's chart and provide Counselor Supervisor a copy for tracking purposes. Counselor Supervisor will audit the patient's chart to ensure follow-up is completed. Counselor Supervisor will monitor throughout the month to see if follow-up has been completed. |
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.
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Observations
Based on a review of client records, the facility ' s policy and procedure manual and discussions with facility staff, the facility failed to comply with plans of correction 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 July 27, 2022, January 11, 2023, May 16, 2023, and August 9, 2023, licensing inspections. This deficiency was found again during this licensing inspection.
A plan of correction for failing to develop individual treatment plans with the facility ' s policy time frame was cited during the May 16, 2023, and August 9, 2023, licensing inspection. This deficiency was found again during this licensing inspection.
A plan of correction for failing to ensure that patients receive on average 2.5 hours of psychotherapy per month during the patient ' s first 2 years was cited for the July 27, 2022, January 11, 2023, May 16, 2023, and August 9, 2023, licensing inspections. This deficiency was found again during this licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment Center Director and Counselor Supervisor will follow the plan of correction for all citations received during this inspection. Treatment Center Director will ensure that clinic staff is following state regulations and plan of correction by monitoring compliance regularly. Treatment Center Director will provide training to all departments to ensure that plan of correction is implemented and followed. Treatment Center Director will review policies with clinic staff during ongoing trainings. |