INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 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, Polaris Renewal Services Inc. MedMark Treatment Centers Lemont Furnace 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee #3 was hired as a Clinical Supervisor on July 17, 2022 and was still acting in that position. Employee #3 was reported to have 30 hours per week devoted to their 28 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 30/40 = .75(FTE); 28/.75= 37.3, which equals to a client/counselor ratio of 37:1.
This finding was reviewed with facility staff during the licensing process
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Plan of Correction
Facility Director reassigned two patients from Employee #3's caseload to ensure FTE counselor caseload equals a 35/1 client/staff ratio. Facility Director will monitor counselor caseload calculation and client/staff ratio to ensure all counselors are at or below the regulation limit of 35/1. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to complete random urinalysis at least monthly in one of eight patient records.
Patient # 1 was admitted on March 18, 2021 and was still active at the time of the inspection. There was no documentation of a urinalysis done in November 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Counselors will run report in SAMMS EMR system the last week of each month to identify any patients who have not provided a UA through SAMMS EMR randomly populated UA requests and submit list to Facility Director. Facility Director will cross reference patients who are listed versus take home pick up days to ensure pick up days do not conflict with randomly populated UA requests. Any patients that are identified as pick up day conflicting with randomly populated UA, Facility Director will place a forced hold on account to prompt UA to ensure completion of monthly UA screens. |
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 a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in one out of two applicable records.
Patient #5 was admitted on January 3, 2022 and was still active at the time of the inspection. The annual clinical evaluation was due on January 3, 2024; however, there was no evaluation documented in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors are required to complete weekly tracker spreadsheet which lists due dates for annual clinical evaluations. Counselors submit tracker spreadsheets to Facility Director and Counselor Supervisor weekly. Counselor Supervisor completes Tracker summary sheets for each counselor which lists any annual evaluations that are due that week. The Tracker Summary is given to counselors each Monday and each item must be listed when completed throughout the week and then returned to Counselor Supervisor to review and sign by every Friday. After Counselor Supervisor reviews completed weekly tracker summary, it will then be submitted to Facility Director. |
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 within guidelines established by the facility's policy and procedures manual in four of four applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within 30 days following admission.
Client #2 was admitted on November 16, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 16, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #3 was admitted on November 14, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 14, 2023; however, there was no documentation of it being completed at the time of the inspection.
Client #4 was admitted on January 4, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 4, 2024; however, there was no documentation of it being completed at the time of the inspection.
Client #6 was admitted on April 21, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 21, 2023; however, it was not completed until August 21, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors are required to complete weekly tracker spreadsheet which lists 30 day due dates following admission for comprehensive treatment plans. Counselors submit tracker spreadsheets to Facility Director and Counselor Supervisor weekly. Counselor Supervisor completes Tracker summary sheets for each counselor which lists any comprehensive treatment plans that are due that week. The Tracker Summary is given to counselors each Monday and each item must be listed when completed throughout the week and then returned to Counselor Supervisor to review and sign by every Friday. After Counselor Supervisor reviews completed weekly tracker summary, it will then be submitted to Facility Director. |
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 two out of five records reviewed.
Client #1 was admitted on June 30, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 10, 2023 and the next update was due no later than July 10, 2023; however, the next update was completed on August 14, 2023.
Client #5 was admitted on January 3, 2022 and was still active at the time of the inspection. A treatment plan update was completed on November 14, 2023 and the next update was due no later than January 14,2024; however, no update was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors are required to complete weekly tracker spreadsheet which lists 60 day due dates for comprehensive treatment plans. Counselors submit tracker spreadsheets to Facility Director and Counselor Supervisor weekly. Counselor Supervisor completes Tracker summary sheets for each counselor which lists any comprehensive treatment plans that are due that week. The Tracker Summary is given to counselors each Monday and each item must be listed when completed throughout the week and then returned to Counselor Supervisor to review and sign by every Friday. After Counselor Supervisor reviews completed weekly tracker summary, it will then be submitted to Facility Director. |
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 a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states a case consultation is to be completed every three months within the first year and yearly after.
Client #2 was admitted on November 16, 2023 and was still active at the time of the inspection. A case consultation would be due by February 16, 2024, however there was none documented in the record at the time of the inspection.
Client #3 was admitted on November 14, 2023 and was still active at the time of the inspection. A case consultation was due on February 14, 2024; however, there was none documented in the record at the time of the inspection.
Client #5 was admitted on January 3, 2022 and was still active at the time of the inspection. A case consultation was due January 3, 2024; however, there was none documented in the record at the time of the inspection.
Client #6 was admitted on April 21, 2023 and was still active at the time of the inspection. A case consultation was due no later than July 21, 2023; however, there was none documented in the record at the time of the inspection.
Client #8 was admitted on January 30, 2020 was still active at the time of the inspection. A case consultation was due no later than January 30, 2024; however, there was none documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All counselors are required to complete weekly tracker spreadsheet which lists 90 day due dates for case consults for the first year of treatment and then completed yearly thereafter. Counselors submit tracker spreadsheets to Facility Director and Counselor Supervisor weekly. Counselor Supervisor completes Tracker summary sheets for each counselor which lists any case consults that are due that week. The Tracker Summary is given to counselors each Monday and each item must be listed when completed throughout the week and then returned to Counselor Supervisor to review and sign by every Friday. After Counselor Supervisor reviews completed weekly tracker summary, it will then be submitted to Facility Director. |
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 provide a complete client record, which is to include a discharge summary in one of two applicable client records reviewed.
Client #8 was admitted on January 30, 2020 was discharged on April 7, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors are required to complete weekly tracker spreadsheet which lists due dates for discharge summaries. Counselors submit tracker spreadsheets to Facility Director and Counselor Supervisor weekly. Counselor Supervisor completes Tracker summary sheets for each counselor which lists any discharge summaries that are due that week. The Tracker Summary is given to counselors each Monday and each item must be listed when completed throughout the week and then returned to Counselor Supervisor to review and sign by every Friday. After Counselor Supervisor reviews completed weekly tracker summary, it will then be submitted to Facility Director. |
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 in two out of two discharged records reviewed.
Client #7 was admitted on January 11, 2023 and was discharged on October 17, 2023.
Client #8 was admitted on January 30, 2020 was discharged on April 7, 2023.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
All counselors are required to complete weekly tracker spreadsheet which lists 7 day and 30 day due dates for discharge follow ups. Counselors submit tracker spreadsheets to Facility Director and Counselor Supervisor weekly. Counselor Supervisor completes Tracker summary sheets for each counselor which lists any discharge follow ups that are due that week. The Tracker Summary is given to counselors each Monday and each item must be listed when completed throughout the week and then returned to Counselor Supervisor to review and sign by every Friday. After Counselor Supervisor reviews completed weekly tracker summary, it will then be submitted to Facility Director. |