INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on July 29-31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, MedMark Treatment Centers of Pennsylvania, Inc. 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark's policy and procedure manual will be updated to include the addition of a policy that states that "MedMark will hire staff members who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population". The Facility Director will ensure that this is completed during our annual review of the revised policy and procedure manual. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to document that all counselors met both the educational and experiential requirements for the position.
Personnel records were reviewed on July 29, 2019. Staff #10 was hired as a counselor on June 10, 2019. Staff #10 has a bachelor's degree in psychology, which meets the educational requirement; however, staff #10 does not have any documentation of the one year of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to hiring new clinical staff, the Facility Director will ensure that all qualifications are met with regards to education and experience. The Facility Director will review the resume, application and transcripts of a candidate and ensure that the correct job description is distributed and the correct amount of supervision is done. Facility Director will ensure ongoing compliance by review of employee charts. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to prohibit heaters that are not permanently mounted or installed.
A physical plant inspection was conducted on July 30, 2019. At the time of the inspection, there was a portable heater present in the counseling office that was used by the licensing specialist.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed physical plant regulations, reminding all staff that space heaters are prohibited, during the staff meeting on August 14th. The Facility Director will ensure compliance with physical plant regulations during our regular physical plant walkthrough self-inspections. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document annual individual staff performance evaluations which were signed by the employee.
Personnel and training records were reviewed on July 29, 2019. Staff #1 was hired as the project director on December 1, 2017. There was no 2018 written performance evaluation documented in staff record #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All personnel will have an annual performance evaluation on file, moving forward. The Facility Director will ensure that there is one on file for all employees, and will ensure compliance during regular audits of the employee files. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to document a written procedure which complies with 4 Pa. Code 255.5 regarding the disclosure of client-oriented information.
A review of the policy and procedure manual was completed as part of the 2019 licensure review and methadone monitoring inspection. There was no policy regarding confidentiality compliance with 4 Pa Code 255.5 documented in the policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark's policy and procedure manual will be revised to include a policy regarding confidentiality compliance with 4 Pa Code 255.5. The Facility Director will ensure compliance during the annual review of the revised MedMark policies. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
The facility failed to develop and maintain a data collection and record keeping system that allows for the efficient retrieval of data and for the identification of clients' admissions and discharges within a specific time period.
Client record lists were provided to the licensing specialist during the onsite inspection, July 29-31, 2019. The lists provided did not include admission dates, which made it difficult to select client records that met the criteria for the licensing period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will contact the SAMMS support team to request a custom report that includes admission and discharge dates for patients. The Facility Director will ensure that this report is added and accessible to auditors when they are onsite. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to document a policy and procedure which included reporting an unusual incident to DDAP within 3 business days in the required categories.
A review of the policy and procedure manual was completed as part of the 2019 licensure review and methadone monitoring inspection. There was no policy and procedure documented which included the reporting of required unusual incidents to DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark's Policy and Procedure manual will be updated to include the following addition to our unusual incident reporting policy that "unusual incidents must be reported to DDAP within 3 business days". The Facility Director will ensure compliance during the annual review of the policy manual. |
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
The facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
For the week of May 12-18, 2019, the facility census was 472, requiring at least 47.2 physician hours. There were 44 physician hours documented.
For the week of June 9-15, 2019, the facility census was 476, requiring at least 47.6 physician hours. There were 46 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will utilize a paper calendar that will be filled in by each doctor on their scheduled work days to note where their hours were actually worked (Greensburg or Blairsville). The Facility Director will ensure compliance by reviewing this calendar weekly and ensuring adequate medical coverage for the current census. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
The facility failed to document written policies and procedures relating to rescinding take-home medication privileges.
A review of the policy and procedure manual was completed as part of the 2019 licensure review and methadone monitoring inspection. There was no policy and procedure documented for the rescinding of take home privledges documented in the policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2018 licensing inspection.
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Plan of Correction
MedMark's policy and procedure manual will be updated to include a policy that covers rescinding of take home privileges. The Facility Director will ensure compliance with this addition during the annual review of the policy manual. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
The facility failed to develop policies regarding involuntary terminations which limited the conditions to those listed in regulation.
A review of the policy and procedure manual was completed as part of the 2019 licensure review and methadone monitoring inspection. The policy and procedure documented conditions for involuntary termination which exceeded those listed in regulation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark's policy and procedure manual will be updated to align the conditions for involuntary termination with the PA state regulations. The Facility Director will ensure compliance when the annual review of the policy manual revisions takes place. |