INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 15-16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services Inc. / MedMark Treatment Centers Lemont Furnace 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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704.11(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, the facility failed to document TB/STD and HIV/AIDS training for all employees within the required timeframe in one of one personnel record.
Staff #6 was hired as a support staff on November 18, 2019. TB/STD and HIV/AIDS was due to be completed by November 18, 2021. There was no documentation of TB/STD or HIV/AIDS training in personnel record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #6 completed Basic HIV training on 3/30/23 and TB/STD training on 4/6/23. Facility Director will review personnel files monthly to ensure all required training is completed. |
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 at least every sixty days in two of four client records.
Client #2 was admitted on June 30, 2022 and is currently an active client. A treatment plan was completed on June 30, 2022. Treatment plan updates were due to be completed by August 30 and September 30, 2022. The next treatment plan update completed was dated November 28, 2022.
Client #5 was admitted on October 1, 2020 and is currently an active client. A treatment plan update was completed on October 10, 2022. Treatment plan updates were due to be completed by December 10, 2022 and February 10, 2023. The next treatment plan update was completed on March 8, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Counseling staff are required to complete a spreadsheet tracker with treatment plan due dates for each patient on caseload and the spreadsheet is submitted to Counseling Supervisor weekly and Facility Director monthly for review to ensure completion at least every 60 days. |
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 document follow up contact within seven days of discharge, per agency policy, in one of two client records.
Client #7 was admitted on October 13, 2022 and discharged on January 12, 2023. There was no follow up contact documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Counseling staff are required to complete a spreadsheet tracker with discharge follow up due dates for each patient on caseload and the spreadsheet is submitted to Counseling Supervisor weekly and Facility Director monthly for review to ensure completion every 7 and 30 days post discharge. |