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 26-27, 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 Washington 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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704.7(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
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, who was hired as a counselor on July 7, 2022, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment Center Director reached out to BayMark Human Resources Dept. who re-issued Employee #4 an offer letter for the position of Counselor Assistant. Employee #4 will remain in the position of Counselor Assistant until one year of experience is acquired. Employee #4 accepted the positon of Counselor Assistant. Treatment Center Director will review all future hires to ensure the candidate meets states regulations for the position. |
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.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe in three out of five personnel files reviewed.
Employee # 2 was hired as a counselor on September 3, 2020 and was due to have the communicable disease trainings no later than September 3, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD trainings as of the date of the inspection.
Employee # 3 was hired as a counselor on November 16, 2020 and was due to have the communicable disease trainings no later than November 16, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hired as a counselor assistant on July 27, 2020 and was due to have the communicable disease trainings no later than July 27, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment Center Director provided Lead Nurse with the Department of Drug and Alcohol Programming's Minimum Content Requirements for Pennsylvania Department of Health Approved HIV/AIDS Curriculum. Lead Nurse will develop a training presentation based on the curriculum provided to her by Treatment Center Director by 12/01/2022
Once Lead Nurse develops a six-hour training presentation on HIV/AIDS and a four-hour training presentation on TB/STD she will provide it to Employee #'s 2, 3, and 7, and any other new staff by 02/01/2023. Treatment Center Director will schedule all future hires to receive the HIV/AIDS and TB/STD trainings within the first year of employment.
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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 September 2021 through July 2022 fire drill logs during the inspection, the facility failed to document the time of the fire drill, the amount of time it took for evacuation, and the exit route used.
Fire drill log for June 2022 did not document the time it took to evacuate, and the time drill took place.
Fire drill logs for September 2021 through July 2022 did not document exit route used.
These findings were reviewed by facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will document all fire and emergency drills properly by maintaining 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. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the September 2021 through July 2022 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
During February, May, June and July 2022 there was no documentation as to whether the fire alarm or smoke detector was set off during the drill.
This is a repeat citation from August 26-27, 2021 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Every month Treatment Center Director will conduct a fire drill by sounding a fire alarm. Treatment Center Director will document the drill, including the use of the fire alarm along with 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 and any problems encountered during the drill. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of the patient records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of the patient in one patient record out of ten patient records reviewed.
Patient #6 was admitted on November 12, 2021 and was still active at the time of the inspection. A release of information form for an emergency contact was dated November 12, 2021.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All Substance Abuse Counselors will review the files of patients on their caseloads to ensure that every patient has a current release of information for an emergency contact, along with the signature of the patient. During monthly supervision sessions with all Counselors, Treatment Center Director will monitor that all patients, including new admissions, have a current, signed emergency contact release. |
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 six out of ten patient records reviewed.
Patient #1 was admitted on January 13, 2021 and was still active at the time of the inspection. A release of information form for three legal representatives, and three social service agencies dated June 22, 2022 did not have documentation that the patient was offered a copy of the consent.
Patient #2 was admitted on July 18, 2019 and was still active at the time of the inspection. A release of information form for an emergency contact dated July 22, 2022 did not have documentation that the patient was offered a copy of the consent form.
Patient #5 was admitted on January 20, 2022 and was still active at the time of the inspection. A release of information form for an emergency contact dated January 20, 2022 did not have documentation that the patient was offered a copy of the consent form.
Patient #6 was admitted on November 12, 2021 and was still active at the time of the inspection. A release of information form for an emergency contact dated November 12, 2021 did not have documentation that the patient was offered a copy of the consent form.
Patient #7 was admitted March 1, 2022 and was still active at the time of the inspection. A release of information for an emergency contact and a drug and alcohol facility dated March 1, 2022 did not have documentation that the patient was offered a copy of the consent.
Patient # 10 was admitted on October 5, 2021 and discharged on July 13, 2022. A release of information for an emergency contact dated October 5, 2021 did not have documentation that the patient was offered a copy of the consent.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment Center Director contacted appropriate resources to update the pre-loaded Authorization to Release/Request PHI form to include that a copy of form was accepted or declined by patient. In the meantime, all staff will document whether or not patient accepted a copy of the release in the notes section. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of patient records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on June 30, 2022 which involved law enforcement presence at the facility. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will file a written incident report with DDAP within 3 days of any unusual incident in which police, fire, or ambulance services are present at the facility. |
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
Based on a review of the physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of May 22-29, 2022, the patient census was 324. The facility was required to provide at least 32.4 physician hours. There were 29 physician hours documented.
During the week of June 5-11, 2022, the patient census was 322. The facility was required to provide at least 32.2 physician hours. There were 29 physician hours documented.
During the week of June 12-18, 2022, the patient census was 319. The facility was required to provide at least 31.9 physician hours. There were 29 physician hours documented.
During the week of June 26-July 2, 2022, the patient census was 320. The facility was required to provide at least 32 physician hours. There were 31 physician hours documented.
During the week of July 3-8, 2022, the patient census was 323. The facility was required to provide at least 32.3 physician hours. There were 30 physician hours documented.
During the week of July 10-18, 2022, the patient census was 323. The facility was required to provide at least 32.3 physician hours. There were 30 physician hours documented.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will monitor patient enrollment weekly to ensure that there is a Physician or Certified Nurse Practitioner available to provide at least one hour per week of services for every 10 patients. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of the physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census. Of the one hour for every ten patient physician onsite requirement, one-third shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
During the week of May 22-29, 2022, the patient census was 324. The facility was required to provide at least 32.4 onsite physician hours. A physician shall provide at least one-third of the 32.4 hours, which equals 10.8 hours. The physician only provided 10 hours.
During the week of June 5-11, 2022, the patient census was 322. The facility was required to provide at least 32.2 onsite physician hours. A physician shall provide at least one-third of the 32.2 hours, which equals 10.7 hours. The physician only provided 10 hours.
During the week of June 12-18, 2022, the patient census was 319. The facility was required to provide at least 31.9 onsite physician hours. A physician shall provide at least one-third of the 31.9 hours, which equals 10.6 hours. The physician only provided 10 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will closely monitor patient enrollment on a weekly basis to provide adequate Physician treatment time to patient population, meaning that one-third of all required narcotic treatment physician time will be provided by a narcotic treatment physician. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of the patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient in one out of four records reviewed.
Patient # 10 was admitted on October 5, 2021 and was discharged on July 13, 2022. An informed consent was signed by the patient on October 11, 2021; however, the patient received the first dose on October 5, 2021.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Medical Director will complete the informed, voluntary, written consent with all new admissions before they are administered any medication. Treatment Center Director will review all admission documentation once it is completed to ensure that the informed consent and all other admission documentation is completed correctly. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 one hour per month of group or individual psychotherapy during the third and fourth year of treatment, in two out of two applicable records reviewed.
Patient #2 was admitted on July 18, 2019 and was still active at the time of the inspection. In March of 2021, the patient only received a half hour of individual psychotherapy session and no group sessions.
Patient # 8 was admitted on December 13, 2019 and discharged on March 31, 2022. In January 2022 the patient only received twenty minutes of individual psychotherapy session and no group sessions. In December 2021 the patient only received forty-five minutes of individual psychotherapy and no group sessions.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment Center Director will monitor on a monthly basis, during Counselor supervision sessions, that all Substance Abuse Counselors are providing individualized psychotherapy services that meet the following requirements: (2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of one applicable record.
Patient #7 was admitted on March 1, 2022 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment Center Director will monitor on a monthly basis, during Counselor supervision sessions, that all Substance Abuse Counselors are documenting in writing that they notified a transferring narcotic treatment program of a patient's admission, their dosage amount, and when the initial dose was administered. |
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 six out of six applicable records.
Patient #1 was admitted on January 13, 2021 and was still active at the time of the inspection. The annual physical examination was due January 13, 2022; however, was completed on January 26, 2022.
Patient #2 was admitted on July 18, 2019 and was still active at the time of the inspection. The annual physical examination was due July 18, 2022: however, there is no documentation one was completed.
Patient #3 was admitted on March 15, 2018 and was still active at the time of the inspection. The annual physical examination was due March 15, 2022; however, was completed on March 23, 2022.
Patient #4 was admitted on May 5, 2016 and was still active at the time of the inspection. The annual physical examination was due May 5, 2022: however, was completed on May 26, 2022.
Patient #8 was admitted on December 13, 2019 and was discharged on March 31, 2022. An annual physical examination was due December 13, 2021: however, was completed on December 21, 2021.
Patient #9 was admitted on February 13, 2018 and was still active at the time of the inspection. An annual physical was due February 13, 2022; however, was completed on February 19, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment Center Director and Medical Director will monitor on a monthly basis, during Counselor supervision sessions, that all Substance Abuse Counselors and medical staff are completing patient annual reevaluations before their due date. Treatment Center Director will also monitor that all patient files include the results of all annual physical examinations given by this narcotic treatment program, which includes an annual reevaluation by the narcotic treatment physician. |
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 five out of six applicable records.
Patient #1 was admitted on January 13, 2021 and was still active at the time of the inspection. The annual clinical evaluation was due January 13, 2022; however, was completed on February 23, 2022.
Patient #2 was admitted on July 18, 2019 and was still active at the time of the inspection. The annual clinical evaluation was due on July 18, 2022; however, was completed on July 22, 2022.
Patient #3 was admitted on March 15, 2018 and was still active at the time of the inspection. The annual clinical evaluation was due March 15, 2022 and as of the date of the inspection has not been completed.
Patient #4 was admitted on May 5, 2016 and was still active at the time of the inspection. The annual clinical evaluation was due on May 5, 2022 and as of the date of the inspection has not been completed.
Patient #9 was admitted on February 13, 2018 and was still active at the time of the inspection. The annual clinical evaluation was due on February 13, 2022 and as of the date of this inspection has not been completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Medical Director will review, sign and date all patient annual evaluations. All Substance Abuse Counselors will complete patient annual evaluations by the patient's admission date the following year, the annual evaluation period will begin on the date of patient's admission to this narcotic treatment program and will recur annually. The annual patient evaluations will address the following areas: employment, education and training, legal standing, current substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives, and family and community supports. |
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 patient records, the facility failed to document a comprehensive treatment plan within thirty days of admission established by the facility's policy and procedures manual in three out of four applicable records reviewed.
Patient #5 was admitted on January 20, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 20, 2022; however, it was not completed until March 21, 2022.
Patient #6 was admitted on November 12, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 12, 2021; however, it was not completed until January 12, 2022.
Patient # 10 was admitted on October 5, 2021 and was discharged on July 13, 2022. A comprehensive treatment plan was due no later than November 5, 2021; however it was not completed until November 11, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will monitor on a monthly basis, during Counselor supervision sessions, that all Substance Abuse Counselors are completing an individual treatment and rehabilitation plan with all new admissions within 30 days of their admission date. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of patient records, the facility failed to document proposed type of support services on individual treatment plans in three out of ten records reviewed.
Patient #1 was admitted on January 13, 2021 and was still active at the time of the inspection.
Patient #4 was admitted on May 5, 2016 and was still active at the time of the inspection.
Patient #7 was admitted on March 1, 2022 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment Center Director will monitor on a monthly basis, during Counselor supervision sessions, that all Substance Abuse Counselors are documenting each patient's need for supportive services or the type of supportive services in place, in the patient's treatment and rehabilitation plans. |
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 patient records, the facility failed to document treatment plan updates within the regulatory timeframe in nine out of ten records reviewed.
Patient #1 was admitted on January 13, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 10, 2022 and the next update was due no later than May 10, 2022; however, the next update was completed on May 18, 2022. The next update was due no later than July 18, 2022; however, was completed on July 25, 2022.
Patient # 2 was admitted on July 18, 2019 and was still active at the time of the inspection. A treatment plan update was completed on November 11, 2021 and the next update was due no later than January 11, 2022: however was completed on March 14, 2022. The next update was due no later than May 14, 2022; however, was completed on June 3, 2022.
Patient # 3 was admitted on March 15, 2018 and was still active at the time of the inspection. A treatment plan update was completed on March 24, 2022 and the next update was due no later than May 24, 2022: however was completed on June 1, 2022.
Patient #4 was admitted on May 5, 2016 and was still active at the time of the inspection. An updated treatment plan was completed on November 4, 2021. The next update was due no later than January 4, 2022: however, there were no updates completed.
Patient #6 was admitted on November 12, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 12, 2022 and the next update was due no later than March 12, 2022; however, it was completed on April 1, 2022.
Patient #7 was admitted on March 1, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 24, 2022 and the next update was due no later than July 24, 2022; however, it was completed on July 26, 2022.
Patient # 8 was admitted on December 13, 2019 and was discharged on March 31, 2022. An updated treatment plan was completed on October 12, 2021 and the next update was due no later than December 12, 2021; however was completed on December 21, 2021.
Patient #9 was admitted on February 13, 2018 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 was completed on May 13, 2022. The next date was due no later than July 13, 2022; however, was completed on July 22, 2022.
Patient#10 was admitted on October 5, 2021 and was discharged on July 13, 2022. A comprehensive treatment plan was completed on November 11, 2021 and the next update was due no later than January 11, 2022; however was completed on January 18, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Treatment Center Director will monitor on a monthly basis, during Counselor supervision sessions, that all Substance Abuse Counselors are reviewing and updating every patient's treatment and rehabilitation plan every 60 days, by the date of the previous plan. |