INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 10-11, 2025 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:
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of applicable staff records, the facility failed to provide a mechanism to provide feedback on a completed training in accordance with the facility policy and procedure manual in three of three records.
The facility policy and procedure manual indicated that staff are to complete training feedback once the training is completed.
Staff #2 was hired on as a counselor on November 2, 2020, promoted to clinical supervisor on July 17, 2022, and was still in this position at the time of the inspection. The facility was unable to provide feedback collected from trainings Staff #2 had participated in during 2024 training year.
Staff #3 was hired on as a counselor on April 7, 2022 and was still in this position at the time of the inspection. The facility was unable to provide feedback collected from trainings Staff #3 had participated in during 2024 training year.
Staff #6 was hired on as a counselor on April 17, 2023 and was still in this position at the time of the inspection. The facility was unable to provide feedback collected from trainings Staff #6 had participated in during 2024 training year.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility Director will implement a tracking system to ensure compliance with required training hours and feedback form completion This system will be reviewed with staff to allow for education and understanding of required regulations. The Facility Director and Counseling Supervisor will conduct a monthly training status review to identify any lapses in staff member training. Feedback forms will be developed for all training and completed by staff. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide written individual training plans in six of six records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will develop, in conjunction with Counseling Supervisor and staff members, individualized training plans for all staff detailing areas of training to ensure compliance. This will be monitored monthly. Future training plans will be created annually each year for implementation each training year. The Facility Director will keep personnel training records updated for each staff member. Training feedback forms will be maintained for internal and external training in each employee training records |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in two of two staff records.
Staff #5 was hired on as a counselor on January 22, 2024 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by January 22, 2025. There was no documentation that these trainings were completed.
Staff #6 was hired on as a counselor on April 17, 2023 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by April 17, 2024. There was no documentation that these trainings were completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will ensure that all new clinical employees are scheduled for HIV/AIDS and TB/STD training within the first quarter annually. The Facility Director will keep updated personnel records with training records for each staff member to ensure all staff complete the training within the first 2 years of employment. The Facility Director will ensure ongoing compliance with this when creating a training plan for that employee and by auditing employee records monthly. Staff #1, Staff #4, Staff #5, and Staff #6 received the appropriate training on March 28, 2025. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of the personnel training records, the facility failed to have counselors complete at least 25 clock hours of annual training in two of two records.
Staff #3 was hired on as a counselor on April 7, 2022 and was still in this position at the time of the inspection. Staff #3 had documented fifteen hours and thirty minutes of training for the January 1, 2024 through December 31, 2024 training year.
Staff #6 was hired on as a counselor on April 17, 2023 and was still in this position at the time of the inspection. Staff #6 had documented nineteen hours and thirty minutes of training for the January 1, 2024 through December 31, 2024 training year.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Facility Director and Counseling Supervisor will monitor Counselor training hours to ensure that each counselor receives 25 hours of training as required. The Facility Director will work with the internal training department to ensure that the in-house training provides at least 25 hours. Facility Director will also add on external training programs relevant to the counselor's job duties. |
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.
|
Observations
Based on review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload in the outpatient program exceeded 35 active clients for one of six staff.
Staff #6 was hired on as a counselor on April 17, 2023 and was still in this position at the time of the inspection. Staff #6 was reported to have 32 hours per week devoted to their 35 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 32/40 = .8(FTE); 35/.8 = 43, which equals to a client/counselor ratio of 43:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 26-27, 2024 annual licensing inspection.
|
Plan of Correction
Facility Director and Counseling Supervisor will evaluate all individual counselor caseloads to adjust them such that they are following regulations. The Facility Director and Counseling Supervisor will monitor counselor caseloads utilizing appropriate formula calculation for client/staff ratios monthly to ensure that all counselors are following the 35:1 ratio. The newly approved counselor position will aid in bringing staffing ratios into compliance. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility fire drill log for the months of February 2024 through February 2025, the facility failed to provide documentation of a fire drill being conducted the months of January 2025 and February 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will coordinate and conduct random unannounced fire drills monthly. The Regional Director of Operations will ensure ongoing compliance, the completed drill form will be maintained in the Health and Safety Binder and uploaded to the Regional Director of Operations SharePoint site for ensuring monthly compliance by the last day of each month. |
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 applicable patient records reviewed, the facility failed to have an annual evaluation of each patient ' s status that was completed by the patient ' s counselor and was reviewed, dated, and signed by the medical director in three of three records.
The annual evaluation period shall start on the date of the patient ' s admission to a narcotic treatment program.
Patient #5 was admitted to on September 27, 2022 and was still active at the time of the inspection. The annual evaluation was due by September 27, 2024, however this was not completed at the time of the inspection.
Patient #6 was admitted to on December 6, 2022 and was still active at the time of the inspection. The annual evaluation was due by December 6, 2024, however this was not completed at the time of the inspection.
Patient #7 was admitted to on October 28, 2021 and was still active at the time of the inspection. The annual evaluation was completed on October 29, 2024, however this was not signed by the medical director at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 26-27, 2024 annual licensing inspection.
|
Plan of Correction
The Facility Director and Counseling Supervisor will ensure the Clinical Staff will be trained in requirements for psychotherapy based on the phase that the patient is in. The Clinical Training Manager will complete the training. The Facility Director and Clinical Supervisor will monitor compliance through clinical chart audits and ensure compliance and address any issues individually with the counselor. |
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 applicable client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manual in one of two records.
The project policy and procedure manual indicated an initial comprehensive treatment and rehabilitation plan be completed within thirty days of admission into the program.
Client #1 was admitted on August 15, 2024 and was still active at the time of the inspection. An initial comprehensive treatment plan was due no later than October 15, 2024, however this was not completed until December 9, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 26-27, 2024 annual licensing inspection.
|
Plan of Correction
Facility Director and Counseling Supervisor will retrain all counseling staff on the requirements of Treatment Planning. Software updates to the Electronic Medical Record System utilized are being installed and this training will be ongoing. Tracking summaries that highlight due dates of services following admission 30, 60 and annually will be closely monitored for adherence and follow-up by the Facility Director and Counseling Supervisor. Initiative-taking approaches will be instituted such that we identify actions that need to be done prior to the due dates. Additional random chart audits will be performed monthly with weekly audits being done on new patients to ensure compliance. Signature audits will also be instituted. Staff training on policy and time frames will occur on a quarterly basis emphasizing tracking accountability. |
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.
|
Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in four of six applicable records.
Client #3 was admitted on August 12, 2024 and was still active at the time of the inspection. A treatment plan update was completed on November 11, 2024 and the next update was due no later than January 11, 2025; however, the update was completed on January 23, 2025.
Client #5 was admitted on September 27, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 10, 2024 and the next update was due no later than June 10, 2024; however, the update was completed on July 1, 2024.
A treatment plan update was completed on July 1, 2024 and the next update was due no later than September 1, 2024; however, the update was completed on November 21, 2024.
A treatment plan update was completed on November 21, 2024 and the next update was due no later than January 21, 2025; however, this was not completed at the time of the inspection.
Client #6 was admitted on December 6, 2022 and was still active at the time of the inspection. A treatment plan update was completed on October 2, 2024 and the next update was due no later than December 2, 2024; however, the update was completed on December 26, 2024.
Client #7 was admitted on October 28, 2021 and was still active at the time of the inspection. A treatment plan update was completed on December 10, 2024 and the next update was due no later than February 10, 2025; however, the update was completed on February 27, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 26-27, 2024 and March 15-16, 2023 annual licensing inspections.
|
Plan of Correction
The Facility Director is responsible for ensuring that the treatment plans are updated as required. The Facility Director and Counseling Supervisor will meet with the counselors and remind them of the regulation and utilization of the tracking sheet to assist them with compliance. It shall be the responsibility of the Counseling Supervisor to ensure program staff are trained by the Clinical Training Manager on the documentation of the comprehensive treatment plan including patients participating in the treatment planning session and signing their treatment plan. Random chart audits will be performed on each caseload ensuring compliance. |
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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of six applicable records.
The facility policy and procedure manual indicate a case consultation to occur every ninety days during the first year of treatment, then annually thereafter.
Client #3 was admitted on August 12, 2024 and was still active at the time of the inspection. A case consultation was due to occur no later than January 10, 2025, however this was not completed at the time of the inspection.
Client #5 was admitted on September 27, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than September 27, 2024, however this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 26-27, 2024 annual licensing inspection.
|
Plan of Correction
The Facility Director will provide training regarding updated follow-up policy and procedure. The follow-up call must be completed within thirty days after discharge. The Counseling Supervisor will utilize random monthly chart audits to ensure adherence. The Counseling Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of two records.
The policy and procedure manual indicates follow-up contact must be made at seven and thirty days after discharge.
Client #2 was admitted on October 15, 2024 and was discharged on November 5, 2024. There was no documentation of follow-up being completed.
Client #4 was admitted on March 18, 2021 and was discharged on September 26, 2024. There was no documentation of follow-up being completed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the February 26-27, 2024 and March 15-16, 2023 annual licensing inspections.
|
Plan of Correction
The Facility Director will provide training regarding updated follow-up policy and procedure. The follow-up call must be completed within thirty days after discharge. The Counseling Supervisor will utilize random monthly chart audits to ensure adherence. The Counseling Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors.
The Clinical team will keep track of documents due at discharge by following a discharge checklist. The Counseling Supervisor will complete chart audits on discharge patients to ensure discharged documents are completed. The Facility Director will review this process with the clinical team and Counseling Supervisor with results documented and placed in employee records.
|
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, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates was submitted and approved by the Department for the February 26-27, 2024 and March 15-16, 2023 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the March 10-11, 2025 annual licensing inspection.
A plan of correction for follow-up contact was submitted and approved by the Department for the February 26-27, 2024 and March 15-16, 2023 annual licensing inspections. Follow-up contact was again found to be a deficiency in the March 10-11, 2025 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility Director, in conjunction with the Regional Director of Operations, will develop Plans of Correction to submit to the Department. Once accepted, Facility Director and Regional Director of Operations will create, review, and implement regular audits of the facility's compliance to all accepted plans of correction submitted and approved by the Department. |