INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 7 - 8, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, MedMark Treatment Centers of Pennsylvania d/b/a MedMark Treatment Centers Greensburg 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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709.28 (c) 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.
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Observations
The facility failed to obtain an informed and voluntary consent form from the client for the disclosure of information contained in the client record in one of twenty-two client records reviewed on August 7 - 8, 2018.
Client # 9 was admitted October 31, 2017 and discharged on December 14, 2017. The facility obtained authorization from the funding entity for treatment services without written consent from the client.
The findings were reviewed with and confirmed by facility staff during the licensing inspection.
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Plan of Correction
The completion of consents will be reviewed with staff during the weekly meeting on 9/19/18. The Clinical Supervisors will provide training on this and will ensure compliance when completing random, monthly chart audits. |
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
The facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving an event at the facility requiring the presence of ambulance personnel based on a review of the facility's unusual incident reports on August 7, 2018.
These incidents occurred on the following dates:
August 15, 2017
August 16, 2017
November 17, 2017
December 20, 2017
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has reviewed the regulations regarding "Unusual Incident Reporting" and will ensure that any incident that requires us to contact emergency personnel will be reported to the Department within 3 business days. Compliance will be monitored by the Director when reviewing the incident reports as they are documented. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
The facility failed to provide documentation of a take-home policy and procedure that included when the patient could be granted take home privileges and how many days of take-home medication could be supplied based on a review of the facility's policy manual on August 7, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark's policy and procedure manual will be updated to include the timeframes for when each level of take home status may be obtained and the number of take home bottles that can be granted at those timeframes. The Facility Director will ensure compliance with this policy addition when the revised policy manual is issued. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to restrict the determination of the patient's initial and subsequent dose to the physician in three of twelve patient records reviewed on August 7 - 8, 2018.
The medication orders were written and signed by the LPN (licensed practical nurse) in the following records:
Patient # 2 was admitted November 7, 2017. The LPN ordered an initial dose of 133 mg methadone on November 8, 2017 5:30 AM. The physician signed the order on November 8, 2017 at 10:37 AM.
Patient # 9 was admitted October 31, 2017 and was discharged on December 14, 2017. The LPN ordered 95 mg methadone on March 9, 2018. The physician signed the order on March 12, 2018.
Patient # 11 was admitted May 13, 2016 and was discharged on April 4, 2018. The LPN ordered 13 mg methadone on March 6, 2018. The physician signed the order on March 7, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The regulations that dictate the ordering of medication have been reviewed with all doctors, the Physician's Assistant and the LPN's. An emphasis on verbal orders was part of this review, that took place on 8/13/18. The Physicians all understand that they are to write their own orders, not dictate orders to the nursing staff, as they have done in some cases, making it look like there are verbal orders being documented. It was also reviewed with the medical staff that if a verbal order is entered into the computer, the Physicians need to sign them within 3 days of them being entered. The Facility Director and Nurse Manager will ensure ongoing compliance with this when conducting random, monthly chart audits. |
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
The narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in two of two patient records reviewed on August 7 - 8, 2018.
Patient # 2 was admitted November 7, 2017.
Patient # 3 was admitted on March 22, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical and Medical staff will be provided a training and will review documentation regarding the process for patient transfers into and out of the program. This will be done by the Clinical Supervisors during the Staff meeting on 9/19/18. The Clinical Supervisors will ensure ongoing compliance while conducting their monthly chart audits. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The narcotic treatment program failed to provide documentation of an unusual incident policy and procedure to respond to the following unusual incidents: inappropriate behavior by a patient causing disruption, selling of drugs on the premises, incident with potential for negative community reaction, theft, burglary or break-in at facility, drug related hospitalization of patient and other unusual incidents the facility believes should be documented. In addition, the facility's policy did not indicate these incidents would be reported to the Department within 48 hours based on a review of the facility's policy manual on August 7, 2018.
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Plan of Correction
MedMark's policy and procedure manual will be updated to include the following under the "Unusual Incident":
inappropriate behavior by a patient causing disruption, selling of drugs on the premises, incident with potential for negative community reaction, theft, burglary or break-in at facility, drug related hospitalization of patient and other unusual incidents the facility believes should be documented. Also, the policy will include that these incidents would be reported to the department within 48 hours. The Facility Director will ensure compliance with this policy addition when the revised policy manual is issued. |