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 3-4, 2021 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 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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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 client records, the facility failed to document a written transfer acknowledgement in two of two client records.
Client #5 was admitted as a transfer on February 23, 2021 and is currently an active client. There was no documentation of a written transfer acknowledgement documented in client record #5.
Client #6 was admitted as a transfer on November 2, 2020 and discharged on December 8, 2020. There was no documentation of a written transfer acknowledgement documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical and medical staff will be trained on the process of transferring patients to another facility during our staff meeting on August 26, 2021. The Facility Director will ensure ongoing compliance when conducting random, monthly chart audits. |
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 as per agency policy of 30 and 90 days, in two of three client records.
Client #4 was admitted on December 9, 2020 and discharged on May 3, 2021. There was no follow up documented in client record #4.
Client #8 was admitted on July 3, 2018 and discharged on April 13, 2021. There was no follow up documented in client record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff will be trained in the process for discharge and follow-up procedures during our staff meeting on August 26, 2021. The Facility Director will ensure compliance with this when conducting random, monthly chart audits. |