INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on July 26 & 27, 2023, 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 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of twelve personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #9 was hired on March 21, 2022 as a counselor assistant and promoted to a counselor on March 21, 2023. Employee #9 has a bachelor's degree with no experience and may counsel clients only under close supervision of a trained counselor or clinical supervisor for the first six months of employment. Employee #9 did not receive any close supervision before being promoted to a counselor.
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week ".
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the state regulations for Counselor Assistant supervision requirements with the Clinical Supervisors on 8/15/2023 during our management meeting. The Facility Director will ensure compliance when reviewing supervision notes each month for all Counselor Assistants.
Employee #9 has been scheduled for weekly close supervision starting the week of 9/4/23 and continuing until the week of 2/26/23. |
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 three out of nine client records reviewed.
Client #3 was admitted on January 18, 2023 and was still active at the time of the inspection. There was a release of information form for the emergency contact dated January 18, 2023 in the record; however there was not documentation that the client was offered a copy of the consent form.
Client #6 was admitted on June 14, 2023 and was still active at the time of the inspection. There was a release of information form for the emergency contact dated June 14, 2023 in the record; however, there was not documentation that the client was offered a copy of the consent form.
Client #8 was admitted on June 13, 2023 and was still active at the time of the inspection. There was a release of information form for the emergency contact dated June 13, 2023 in the record; however there was not documentation that the client was offered a copy of the consent form.
This is a repeat citation from the June 29 & 30, 2022 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will request a revision to the Legal Department of the Releases of Information that are currently in our software. Once revised, all Releases of Information will be updated in all patient files. The Facility Director will ensure that this is completed and ensure ongoing compliance when conducting random, monthly chart audits.
Until the revision to the releases is made, it will be documented in the patient's file that they were offered a copy of any release that they sign. |
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 2.5 hours of psychotherapy per month during the patient ' s first two years of treatment, one hour of which shall be individual psychotherapy, in one out of five applicable records reviewed.
Patient #2 was admitted on February 12, 2021 and was still active at the time of the inspection. The patient only received one hour of psychotherapy in the months of March and June 2023.
This is a repeat citation from the June 30, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During our clinical meeting on 8/10/23 with all of the counselors, the Clinical Supervisors reviewed the requirements for counseling and also the importance of documenting it accurately on treatment plans. The Facility Director will monitor compliance during random, 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 a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in three out of six applicable records.
Patient #1 was admitted on September 25, 2018 and was still active at the time of the inspection. The annual physical examination was due no later than September 25, 2022; however, it wasn ' t completed until September 30, 2022.
Patient #2 was admitted on February 12, 2021 and was still active at the time of the inspection. The annual physical examination was due no later than February 12, 2023; however, it wasn ' t completed until February 24, 2023.
Client #7 was admitted on October 11, 2018 and discharged on December 15, 2022. The annual physical examination was due no later than October 11, 2022; however, one wasn ' t completed until October 28, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All physical exams will be completed prior to the patient's anniversary date. The Facility Director discussed this with the medical staff and we have begun scheduling Physical exams prior to the anniversary date. The Facility Director will ensure ongoing compliance with this when conducting random, monthly chart audits. |
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 evaluation within the regulatory timeframe in three out of six applicable records.
Patient #2 was admitted on February 12, 2021 and was still active at the time of the inspection. The annual evaluation was due no later than February 12, 2023; however, it wasn ' t completed until June 19, 2023.
Patient #4 was admitted on December 10, 2019 and was discharged on May 11, 2023. The annual evaluation was due no later than December 10, 2022; however, there was no documentation that one was completed.
Patient# 7 was admitted on October 11, 2018 and discharged on December 15, 2022. The annual evaluation was due no later than October 18, 2022; however, there was no documentation that one was completed.
This is a repeat citation from the June 30, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All annual evaluations will be completed prior to the patient's anniversary date. We have begun revising our scheduling procedure to alert us to complete these evaluations a month before they are due. The Clinical Supervisors are overseeing the scheduling process and the Facility Director will ensure ongoing compliance when conducting random, monthly chart audits. |
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 document a psychosocial evaluation in one out of three applicable records.
Client #8 was admitted on June 13, 2023 and was still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/10/23, the Clinical Supervisors provided a training to all clinical staff regarding intake documentation, including Psychosocial Evaluation completion. The clinical supervisors will ensure that the psychosocial evaluations are completed with the client when auditing all intake files within 24 hours of intake. The Facility Director will ensure compliance during random, monthly chart audits. |
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 one out of three applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days of admission.
Client #3 was admitted on January 18, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 18, 2023; however, it wasn ' t completed until March 8, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor held a training on Treatment Plan completion and timeframes on 8/10/23 during the clinical team meeting. The Facility Director will ensure ongoing compliance when conducting random, monthly chart audits. |
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 six out of eight records reviewed.
Client #2 was admitted on February 12, 2021 and was still active at the time of the inspection. A treatment plan update was completed on January 6, 2023, and the next update was due no later than March 6, 2023; however, the next update wasn ' t completed until March 16, 2023. A treatment plan update was completed on May 8, 2023, and the next update was due no later than July 8, 2023; however, it wasn ' t completed until July 10, 2023
Client #3 was admitted on January 18, 2023 and was still active at the time of the inspection. A treatment plan was completed on March 8, 2023, and the next update was due no later than May 8, 2023; however, it wasn ' t completed until May 16, 2023. The next update was due no later than July 16, 2023: however, it wasn ' t completed until July 24, 2023.
Client #4 was admitted on December 10, 2019 and was discharged on May 11, 2023. A treatment plan was completed on February 2, 2023, and the next update was due no later than April 2, 2023; however, it wasn ' t completed until May 11, 2023.
Client #5 was admitted on December 28, 2012 and discharged on November 16, 2022. A treatment plan update was completed on September 12, 2022, and the next update was due no later than November 12, 2022; however, it wasn ' t completed until November 16, 2022.
Client #7 was admitted on October 11, 2018 and discharged on December 15, 2022. A treatment plan update was completed on October 12, 2022, and the next update was due no later than December 12, 2022; however, it wasn ' t completed until December 15, 2022.
Client #9 was admitted on March 1, 2018 and was still active at the time of the inspection. A treatment plan update was completed on February 14, 2023, and the next update was due no later than April 14, 2023; however, it wasn ' t completed until April 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor held a training on Treatment Plan completion and timeframes on 8/10/23 during the clinical team meeting. The Facility Director will ensure ongoing compliance when conducting random, monthly chart audits. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of nine applicable records reviewed.
Client #2 was admitted on February 12, 2021 and was still active at the time of the inspection. The treatment plan dated May 8, 2023, indicated one and half hours of group therapy per month and one hour of individual session monthly. There was no documentation of the client receiving one hour of individual therapy in May of 2023.
Client #4 was admitted on December 10, 2019 and was discharged on May 11, 2023. The treatment plan dated February 2, 2023, indicated one and half hours of group therapy per month and one hour of individual session monthly. There was no documentation of the client receiving one hour of individual therapy in February of 2023.
Client #7 was admitted on October 11, 2018 and discharged on December 15, 2022. The treatment plan dated October 12, 2022, indicated one and half hours of group therapy per month and one hour of individual session monthly. There was no documentation of the client receiving one and half hours of group therapy in November 2022.
Client #9 was admitted on March 1, 2018 and was still active at the time of the inspection. The treatment plan dated April 21, 2023, indicated one hour of individual and one group sessions monthly. There was no documentation that the client received group therapy in May of 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor held a training on Treatment Plan completion and timeframes on 8/10/23 during the clinical team meeting. The Facility Director will ensure ongoing compliance when conducting random, monthly chart audits. |
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 follow their policy and procedure time frames for case consultations in three out of seven 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 #2 was admitted on February 12, 2021 and was still active at the time of the inspection. A case consultation was due no later than February 12, 2023, however, there was no documentation that one occurred.
Client #7 was admitted on October 11, 2018 and discharged on December 15, 2022. A case consultation was due no later than October 11, 2022; however, there was no documentation that one occurred.
Client #9 was admitted on March 1, 2018 and was still active at the time of the inspection. A case consultation was due no later than March 1, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor conducted a training to all clinical staff on 8/10/23 that included case consultation completion and time frames. All counselors attended the training and demonstrated an understanding of when case consultations are due during this clinical meeting. The Facility Director will ensure ongoing compliance with this when conducting random, monthly chart audits. |
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 three discharged records reviewed.
Client #5 was admitted on December 28, 2012 and discharged on November 16, 2022. There was no documentation of follow up information.
Client #7 was admitted on October 11, 2018 and discharged on December 15, 2022. There was no documentation of follow up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisors conducted a training with the clinical staff during their Clinical meeting on 8/17/2023 to review the requirements for patient follow-up post discharge. The Facility Director will ensure compliance with this during regular, random chart audits. |