INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on January 11, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Med Mark 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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704.9(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 one applicable personnel record, 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 #7 was hired on September 14, 2022 as a counselor assistant and was still employed at the time of the inspection. Employee # 7 has a high school diploma and 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. There was no documentation that employee #7 received direct observation for the first 3 months or close supervision up until the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The State regulation regarding requirements for the Supervision of Counselor Assistants (704.9) will be reviewed by the Treatment Center Director, who will then provide training to the Clinical Supervisor. The focus of the training will be the types of supervision required, which are direct observation and close supervision, and the amount of supervision that is required for each Counselor Assistant's education level and related experience. Upon each hire of a new Counselor Assistant, the Treatment Center Director and Clinical Supervisor, or trained Counselor who will be providing the supervision, will review the state regulations and determine the level of supervision that will need to be provided. The Treatment Center Director will monitor compliance with supervision regulations by monthly auditing Counselor Assistant's supervision notes and employee files. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of one applicable and personnel record, the facility failed to ensure a counselor assistant documented to the facility director that he is working toward counselor status upon completion of each calendar year.
Employee #7 was hired on September 14, 2022 and was still employed at the time of the inspection. There was no documentation in the personnel record that the counselor assistant was working toward counselor status.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Annually, all Counselor Assistants will provide documentation to Treatment Center Director and Clinical Supervisor that they are actively working towards Counselor status. Treatment Center Director will ensure that the documentation is submitted and stored in employee's file every December, which is the end of the training year. Treatment Center Director will monitor for compliance during monthly employee file audits. |
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.
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Observations
Based on a review of one applicable employee, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in one out of one employee record reviewed.
Employee #7 was hired on September 14, 2022 and was still employed at the time of the inspection. There is no documentation in the personnel record of an individual training plan being developed with input from both the employee and the supervisor.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Treatment Center Director will complete an individualized training plan, that is appropriate to the employee's skill level, with all new employees within 30 days of their hire date. Thereafter training plans will be completed annually, in January, at the beginning of the training year. Training plans will be based on feedback from the employee about their desired areas of training. Treatment Center Director will audit employee files monthly to ensure that all employee training plans are filed and being followed throughout the year. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one record reviewed.
Client #5 was admitted on November 23, 2020 and was discharged on December 19, 2022. An informed and voluntary consent from the client for the disclosure of information form was signed and dated by the client on December 23, 2021, for an emergency contact did not include documentation of the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director and Clinical Supervisor will continue to train staff to obtain an informed and voluntary consent from the patient for the disclosure of information contained in the patient record that included the specific information to be disclosed. Treatment Center Director and Clinical Supervisor will monitor that consents are being completed correctly during weekly random chart audits, clinical supervision sessions, and annual assessments. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included that a copy of the consent was offered to the client and a copy maintained in the client record in four out of seven records reviewed.
Client #1 was admitted on August 23, 2022 and was still active at the time of the inspection. A release of information form for the emergency contact person dated August 23, 2022, did not have documentation that the client was offered a copy of the consent.
Client #3 was admitted on September 1, 2022 and discharged on November 28, 2022. A release of information form for a drug and alcohol facility dated October 11, 2022, did not have documentation that the client was offered a copy of the consent form.
Patient #5 was admitted on November 23, 2020 and discharged on December 19, 2022. A release of information form for an emergency contact person dated December 23, 2021, did not have documentation that the client was offered a copy of the consent form.
Patient #7 was admitted on November 22, 2022 and was still active at the time of the inspection. A release of information form for a government agency dated December 19, 2022, did not have documentation that the client was offered a copy of the consent form.
This is a repeat citation from July 26 & 27, 2022 licensing inspection
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Treatment Center Director has been in contact with the appropriate resources to update the Authorization to Release/Request PHI form to include that patient was offered a copy of the consent. Until the form is updated, all staff will indicate whether patient was offered and accepted or denied a copy of consent in the notes section of the Authorization to Release/Request PHI form. Treatment Center Director and Clinical Supervisor will monitor that this is being included on all consent forms through weekly random chart audits and through clinical supervision sessions. |
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 September 10-16, 2022, the patient census was 315. The facility was required to provide at least 31.5 physician hours. There were only 27 physician hours documented.
During the week of September 17-23, 2022, the patient census was 316. The facility was required to provide at least 31.6 physician hours. There were only 31 physician hours documented.
During the week of September 24-30, 2022, the patient census was 315. The facility was required to provide at least 31.5 physician hours. There were only 31 physician hours documented.
During the week of October 8-14, 2022, the patient census was 313. The facility was required to provide at least 31.3 physician hours. There were only 31 physician hours documented.
During the week of October 15-21, 2022, the patient census was 313. The facility was required to provide at least 31.3 physician hours. There were only 31 physician hours documented.
During the week of October 22-28, 2022, the patient census was 313. The facility was required to provide at least 31.3 physician hours. There were only 31 physician hours documented.
During the week of October 29-November 4, 2022, the patient census was 314. The facility was required to provide at least 31.4 physician hours. There were only 29 physician hours documented.
During the week of November 5-11, 2023, the patient census was 313. The facility was required to provide at least 31.3 physician. There were only 27 physician hours documented.
During the week of November 12-18, 2022, the patient census was 311. The facility was required to provide at least 31.1 physician hours. There were only 31 physician hours documented.
During the week of November 19-25, 2022, the patient census was 311. The facility was required to provide at least 31.1 physician hours. There were only 27 physician hours documented.
During the week of November 26-December 2, 2022, the patient census was 314. The facility was required to provide at least 31.4. There were only 31 physician hours documented.
This is a repeat citation from July 26 & 27, 2022 licensing inspection
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Treatment Center Director will review state regulation (715.6(e) regarding physician staffing with all of the medical providers. Each week, on Friday, the Treatment Center Director will review the census and address any changes in physician staffing that need to be made to ensure compliance for the upcoming week, based on changes in the patient census. The Treatment Center Director will monitor compliance with this regulation by weekly auditing the Patient Activity Report (PAR), which is an enrollment report, vs. the hours worked by all medical providers. |
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 September 10-16, 2022, the patient census was 315. The facility was required to provide at least 31.5 onsite physician hours. A physician shall provide at least one-third of the 31.5 hours, which equals 10.39 hours. The physician only provided 8 hours.
During the week of October 29-November 4, 2022, the patient census was 314. The facility was required to provide at least 31.4 onsite physician hours. A physician shall provide at least one-third of the 31.4 hours, which equals 10.36 hours. The physician only provided 10 hours.
During the week of November 5-11, 2022, the patient census was 313. The facility was required to provide at least 31.3 onsite physician hours. A physician shall provide at least one-third of the 31.3 hours, which equals 10.32 hours. The physician only provided 8 hours.
During the week of November 19-25, 2022, the patient census was 311. The facility was required to provide at least 31.1 onsite physician hours. A physician shall provide at least one-third of the 31.1 hours, which equals 10.26 hours. The physician only provided 8 hours.
This is a repeat citation from July 26 & 27, 2022 licensing inspection
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Treatment Center Director will review the state regulation regarding required physician hours (715.6(e) with all of the medical providers. Special attention will be placed to ensure that Certified Registered Nurse Practitioner/Physician Assistant time does not exceed two-thirds of the required narcotic treatment physician time. At the end of each week, the Treatment Center Director will review the census and address any changes in physician staffing that need to be made to ensure compliance for the upcoming week, based on any changes in the patient census. The Treatment Center Director will monitor compliance with this regulation by weekly auditing the Patient Activity Report (PAR), which is an enrollment report, vs. the hours worked by all medical providers. |
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 an average of two and half hours of psychotherapy per month during the patients first two years, one hour which shall be individual psychotherapy in three out of seven applicable records reviewed.
Patient #1 was admitted on was admitted on August 23, 2022 and was still active at the time of the inspection. In September 2022, the patient only received one and half hours of individual psychotherapy session and no group sessions.
Patient # 2 was admitted on September 23, 2022 and discharged on December 27, 2022. In October 2022 the patient only received one and half hours of individual psychotherapy session and no group sessions.
Patient #5 was admitted on November 23, 2020 and discharged on December 19, 2022. In August 2022 the patient only received two hours of psychotherapy services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Treatment Center Director and Clinical Supervisor will conduct a training for all clinical staff members which will review the state regulations, including required Psychotherapy services (715.19(1). The training will occur on 03/02/2023, it will be a documented training and all staff in attendance will sign off indicating that they received the training and understand the requirements of the regulation. The Treatment Center Director and Clinical Supervisor will monitor that all patients with less than 2 years in treatment receive 2.5 hours per month of psychotherapy, of which at least one hour will be individual, and patients in treatment longer than 2 years will receive at least one hour of psychotherapy per month. Psychotherapy time will be monitored by the Clinical Supervisor weekly through random patient chart audits and supervision sessions. Treatment Center Director will further monitor psychotherapy time through random monthly chart audits. |