INITIAL COMMENTS
|
This report is a result of an unannounced on-site licensure follow-up inspection and methadone monitoring inspection conducted on May 16, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of one 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 #1 was hired on September 21, 2022 and was still employed at the time of the inspection. Employee # 1 has a high school diploma and may counsel clients only under 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.
Employee #1 did not receive the regulatory requirement of three months of direct observation prior to beginning the required nine months of close supervision. Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities. Clear documentation in the weekly supervision notes and in the pertinent client charts must also demonstrate that direct observation is occurring. "
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 is a repeat citation from the January 12, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
When hiring new Counselor Assistants, the Treatment Center Director will review the requirements set forth by the state regulation 704.9 to determine what type of supervision will be needed before the Counselor Assistant provides psychotherapy to patients. The Treatment Center Director will properly screen all potential Counselor Assistant candidates to ensure correct amount of supervision is provided. Counselor Supervisor will follow state regulations when conducting supervision of newly hired Counselor Assistants. Counselor Supervisor will conduct direct observations of Counselor Assistants for the first 3 months and close observation for 9 months thereafter. Treatment Center Director will review the Counselor Supervisor's supervision notes monthly to guarantee that supervision requirements are being met. Employee #1 is no longer employed at this facility. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of two exits on every floor. The facility has a hallway that leads to the second exit blocked by an enclosure made of dry wall due to construction.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Treatment Center Director will ensure that this facility with operate with at least 2 fire exits at all times for the safety of the staff and patients in accordance with 705.28. Fire exits will have proper signage and be free of any obstruction. This citation was corrected on June 8, 2023. |
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.
|
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 four out of seven client records reviewed.
Client #1 was admitted on February 21, 2023 and was still active at the time of the inspection. A release of information form for the emergency contact person dated February 21, 2023, did not have documentation that the client was offered a copy of the consent.
Client #2 was admitted on March 15, 2023 and was still active at the time of the inspection. A release of information form for a family member dated May 2, 2023, did not have documentation that the client was offered a copy of the consent form.
Client #4 was admitted on March 22, 2023 and was still active at the time of the inspection. A release of information form for an emergency contact person dated March 25, 2023, did not have documentation that the client was offered a copy of the consent form.
Client #5 was admitted on February 14, 2023 and was still active at the time of the inspection. A release of information form for an emergency contact dated February 14, 2023, did not have documentation that the client was offered a copy of the consent form.
This is a repeat citation from the July 27, 2022 and January 11, 2023 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Counselor Supervisor will audit all releases at intake, and annually for new and continued stay patients to make sure that each patient is offered a copy of their release of information. Counselors will be responsible for offering each patient a copy of their release and documenting by adding in the note section on the Authorization to Release PHI form at intake, annually and continued treatment releases. Counselor Supervisor will monitor monthly during supervision and report findings to the Treatment Center Director. |
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
|
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 April 16-22, 2023, the patient census was 293. The facility was required to provide at least 29.3 physician hours. There were 15 physician hours documented.
During the week of April 23-29, 2023, the patient census was 290. The facility was required to provide at least 29 physician hours. There were 28 physician hours documented.
During the week of April 30-May 6, 2023, the patient census was 289. The facility was required to provide at least 28.9 physician hours. There were 24 physician hours documented.
During the week of May 7-13, 2023, the patient census was 289. The facility was required to provide at least 28.9 physician hours. There were 26 physician hours documented.
This is a repeat citation from the July 27, 2022 and January 11, 2023 licensing inspections.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Treatment Center Director will review the Medical Director's schedule in relation to the current patient census to assure that the medical hours provided meet or exceed the state staffing regulations. The Treatment Center Director and RDO have been diligent on hiring a second provider to fill the deficient hours.
Update: A mid-level has been hired and is scheduled to begin on July 17, 2023.
|
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.
|
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 seven out of seven applicable records reviewed.
Patient #1 was admitted on February 21, 2023 and was still active at the time of the inspection. In April 2023, the patient only received two hours of individual psychotherapy session and no group sessions.
Patient # 2 was admitted on March 15, 2023 and still active at the time of the inspection. In April 2023 the patient only received half an hour of individual psychotherapy session and no group sessions.
Patient #3 was admitted on March 30, 2023 and was still active at the time of the inspection. In April 2023 the patient only received half an hour of psychotherapy services.
Patient #4 was admitted on March 22, 2023 and was still active at the time of the inspection. In April 2023 the patient only received half an hour of psychotherapy services.
Patient #5 was admitted on February 14, 2023 and was still active at the time of the inspection. In April 2023 the patient did not receive any psychotherapy services.
Patient #6 was admitted on January 18, 2023 and was still active at the time of the inspection. In April 2023 the patient did not receive any psychotherapy services.
Patient #7 was admitted on January 17, 2023 and was still active at the time of the inspection. In April 2023 the patient only received one hour of psychotherapy services.
This is a repeat citation from the July 27, 2022 and January 11, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Upon completion of the clinic renovation, patients will be able to utilize a group room. Patients who have less than two years in treatment and are required 2.5 hours of psychotherapy a month, will attend at least one group session each month. Counselor Supervisor will monitor that Counselors are providing the appropriate amount of psychotherapy hours each month by using internal audit tools, excel spreadsheets for tracking purposes and checking counseling logs daily. Counselor Supervisor will review each Counselor's psychotherapy hours during monthly supervision and on an as needed basis. |
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 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 three out of seven records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.
Client #3 was admitted on March 30, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 30, 2023; however, it was completed on May 5, 2023.
Client #5 was admitted on February 14, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 14, 2023; however, it was not completed until March 21, 2023.
Client #6 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 was not completed until March 8, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
After a patient has been admitted, Counselors will complete a comprehensive treatment plan within 30 days and every 60 days thereafter. The comprehensive treatment plan review will be updated with specific, individualized goals that are patient centered. Counselor Supervisor will monitor all comprehensive treatment plans on a monthly basis to ensure that they are completed by their due date. The Counselor Supervisor will review upcoming treatment plan deadlines during Supervision with Counselors. The Counselor Supervisor will report findings to the Treatment Center Director.
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of two applicable records.
Client #6 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, there was no documentation one was completed.
Client #7 was admitted on January 17, 2023 and was still active at the time of the inspection. A treatment plan was completed on January 31, 2033, and the next update was due no later than March 31, 2023; however, it was completed on April 10, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselor Supervisor will implement a plan where Counselors will place holds for the next treatment plan review dates for their caseload. Counselor Supervisor will randomly review charts using an internal audit tool to confirm that holds are being placed and treatment plans are being updated, per treatment plan regulations, every 60 days. Counselor Supervisor will implement this procedure during bi-weekly group supervision of Counselors. Counselor Supervisor will report internal audits to the Treatment Center Director for review. |
709.17(a)(1) 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:
(1) Failure to comply with a directive issued by the Department.
|
Observations
Based on an onsite unannounced follow up inspection conducted on May 16, 2023, the facility failed to comply with a directive issued by the Department. The facility requested an expansion into an additional suite in the building they are licensed in. The initial request was denied in January 2023 due to construction still being in progress in the suite they requested to expand to.
In February 2023, the facility failed to comply with the Department directive and began utilizing the additional suite for the dosing area and waiting room. The additional suite does not have a second exit and is a fire safety hazard.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
MedMark Treatment Centers will seek approval for new construction plans in the future and will follow the directions set forth by the state. Treatment Center Director will ensure that this facility with operate with at least 2 fire exits at all times for the safety of the staff and patients in accordance with 705.28. Fire exits will have proper signage and be free of any obstruction. This citation was corrected on June 8, 2023. |
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 physician hours was submitted and approved by the Department for the July 27, 2022, annual licensing inspection and January 11, 2023, provisional follow up inspection. Physician Hours were again found to be a deficiency in the May 16, 2023, licensing inspection.
A plan of correction for confidentiality was submitted and approved by the Department for the July 27, 2022, annual licensing inspection, January 11, 2023, provisional follow up inspection. Confidently was again found to be a deficiency in the May 16, 2023, licensing inspection.
A plan of correction for psychotherapy was submitted and approved by the Department for the July 27, 2022, annual licensing inspection, January 11, 2023, provisional follow up inspection. Psychotherapy hours were again found to be a deficiency in the May 16, 2023, licensing inspection.
A plan of correction for counselor assistant supervision was submitted and approved by the Department for the January 11, 2023, provisional follow up inspection. Counselor assistant supervision was again found to be a deficiency in the May 16, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Regional Director of Operations, Treatment Center Director and Counselor Supervisor will work collaboratively to ensure that the plans of correction are being followed. Regional Director of Operations, Treatment Center Director and Counselor Supervisor will monitor these specific citations monthly to prevent occurrence in the future and make sure the plans of corrections are put in place and followed. |