INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6-7, 2022 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- Blairsville PA 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 August 17, 2021 through June 2, 2022 fire drill logs during the inspection, the facility failed to document the time, the amount of time it took for evacuation and exit route used.Fire drill logs August 17, 2021 and October 18, 2021 through January 6, 2022 did not document the time.Fire drill logs August 17, 2021 through June 2, 2022 did not document exit route used.Fire drill logs August 17, 2021 through January 6, 2022 did not document amount of time it took for evacuation.These findings were reviewed by facility staff during the licensing process.
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Plan of Correction
The Facility Director will provide training to the Health and Safety Officer on 8/3/22 on the state's regulations of health and safety, drill requirements and drill documentation. The Facility Director will ensure that the documented, monthly fire drills include all of the required components: Amount of time it took to evacuate, exit routes that were taken and the time of the actual drill. The Facility Director will monitor that the drills are complete when auditing the Health and Safety binder on a quarterly basis. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of a witness in one out of ten records reviewed.Client #8 was admitted on November 4, 2021 and was still active at that the time of the inspection. One release of information dated November 4, 2021 was to a funding source. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide a training to the Clinical Staff regarding the completion of Releases of Information, including all components of a valid release. This training will be held on Thursday, 7/28/22. Compliance will be monitored through random, monthly chart audits conducted by the Facility Director and Clinical Supervisor. |
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 patient records, the facility failed to document that a copy of a patient consent shall be offered to the patient and a copy maintained in the patient record in nine out of ten patient records reviewed. Patient #1 was admitted on August 1, 2018 and was still active at the time of the inspection. One release of information dated June 2, 2022 was to a funding source. Patient #2 was admitted on April 14, 2022 and was still active at the time of the inspection. One release of information dated April 14, 2022 was to an emergency contact.Patient #3 was admitted on January 10, 2022 and was still active at the time of the inspection. One release of information dated January 10, 2022 was to an emergency contact.Patient #5 was admitted on September 10, 2020 and was still active at the time of the inspection. One release of information dated January 10, 2022 was to a funding source.Patient #6 was admitted on September 19, 2018 and was discharged on December 9, 2021. One release of information dated September 20, 2021 was to a funding source.Patient #7 was admitted on August 27, 2015 and was still active at the time of the inspection. One release of information dated August 2, 2021 was to a funding source.Patient #8 was admitted on November 4, 2021 and was still active at the time of the inspection. Three releases of information dated November 4, 2021 were to medical providers.Patient #9 was admitted on March 3, 2022 and was still active at the time of the inspection. A release of information dated March 3, 2022 was to a funding source.Patient #10 was admitted on March 14, 2019 and was still active at the time of the inspection. A release of information dated March 29, 2022 was to a medical provider.These findings were reviewed by facility staff during the licensing process.
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Plan of Correction
The Facility Director has submitted this citation to our legal department to have a section added that reads "patient was offered a copy" "yes or no". Upon correction to the new form, all staff will be trained on the changes and accurate completion.
Once training is complete, all patient records will be updated to have the revised releases added to each patient record. The Facility Director and Clinical Supervisor will monitor for compliance when conducting random, monthly chart audits. |
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 an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in two out of six applicable records reviewed.Patient #5 was admitted on September 10, 2020 and was still active at the time of the inspection. An annual physical was due on September 10, 2021; however, it was not completed until September 30, 2021. Patient #6 was admitted on September 9, 2018 and was discharged on December 9, 2021. An annual physical was due on September 17, 2021; however, it was not completed until September 30, 2021.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director has implemented a system to be put into place to prompt an alert on the patient's record when their annual appointment is due. This alert will be added on patient intake, to ensure patients will not be missed. The Facility Director and Clinical Supervisor will make this part of our ongoing auditing process when reviewing new intake charts. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in eight out of ten records reviewed.Patient #1 was admitted on August 1, 2018 and was still active at the time of the inspection. A treatment plan update was completed on February 24, 2022 and the next update was due no later than April 24, 2022; however, the next update was completed on May 5, 2022. Patient #2 was admitted on February 14, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 3, 2022 and the next update was due no later than May 3, 2022; however, it was completed June 24, 2022.Patient #3 was admitted on January 10, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 28, 2022 and the next update was due no later than April 28, 2022; however, it was completed June 6, 2022.Patient #4 was admitted on September 8, 2014 and was discharged June 7, 2022. A treatment plan update was completed on January 25, 2022 and the next update was due no later than March 25, 2022; however, it was completed April 5, 2022.Patient #5 was admitted on September 10, 2020 and was still active at the time of the inspection. A treatment plan update was completed on March 2, 2022 and the next update was due no later than May 2, 2022; however, it was completed May 24, 2022.Patient #7 was admitted on August 27, 2015 and was still active at the time of the inspection. A treatment plan update was completed on April 11, 2022 and the next update was due no later than June 11, 2022; however, it was completed June 27, 2022.Patient #8 was admitted on November 4, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 9, 2022 and the next update was due no later than May 9, 2022; however, it was completed June 21, 2022.Patient #10 was admitted on March 14, 2019 and was still discharged May 16, 2022. A treatment plan update was completed on December 28, 2021 and the next update was due no later than February 28, 2022; however, it was completed March 29, 2022.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Clinical staff will be provided a training refresher on Treatment Planning on 7/21/22 by the Counselor Supervisor. The Facility Director and Counselor Supervisor will ensure ongoing compliance through ongoing random, monthly auditing of files. |