INITIAL COMMENTS
|
This report is a result of an on-site provisional license and methadone monitoring follow-up inspection conducted on December 12-13, 2024 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 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
|
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the facility failed to document transfer of patient files to the patient's new treatment facility in one out of three applicable records.
Patient #4 was admitted on November 29, 2022 and transferred to another facility on November 26, 2024. At the time of the inspection, there was no documentation that facility transferred patient files to the new facility.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 30-31, 2024 annual licensing inspection.
|
Plan of Correction
When a patient notifies clinical staff of a transfer, the Counselor will send the required documentation within 7 days of the request. Counselors will follow the transfer checklist and ensure that all items are included. Counselors will upload proof that documents have been sent. The Counselor Supervisor will monitor the discharges who transfer to another facility and review the transfer checklist on days when they occur. The Counselor Supervisor provided a training to the clinical staff on 1/9/25 to address this deficiency. The Counselor Supervisor and Treatment Center Director will continue to monitor when transfers occur. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in two out of two applicable records.
Patient #6 was admitted on November 16, 2021 and was still active at the time of the inspection. The annual clinical evaluation was due on November 16, 2024; however, it was not completed at the time of the inspection.
Patient #7 was admitted on November 26, 2019 and was still active at the time of the inspection. The annual clinical evaluation was due on November 26, 2024; however, it was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 30-31, 2024, March 27, 2024 and August 9, 2023 licensing inspections.
|
Plan of Correction
Counselor Supervisor and Treatment Center Director have a printout of clinical annuals due this year. Treatment Center Director has distributed paper copies to each Counselor. Counselor Supervisor will monitor completion of annuals by reviewing the due dates and completion dates. Counselor Supervisor will remind Counselors of upcoming annuals to prevent late annual paperwork. Counselors will track upcoming annuals by utilizing spreadsheets which includes annual due dates. Counselor will follow the provided annual checklist and will submit to Counselor Supervisor upon completion. Counselor Supervisor will review for accuracy. Counselor Supervisor provided a documentation training to the Counseling staff on 1/9/25. |
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 at least every sixty days in one out of two client records reviewed.
Client #6 was admitted on November 16, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 27, 2024 and the next update was due no later than October 27 , 2024; however, it was not completed until November 19, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 30-31, 2024 annual licensing inspection.
|
Plan of Correction
The Counselor Supervisor provided the counseling team with training on 1/9/25 to review state regulations and review the requirements for treatment plans. Counselors will submit treatment plan reviews within 60 days. Counselors will input treatment plan due dates into their spreadsheet to ensure plans are completed prior to their due date. The Counselor Supervisor will monitor the completion of treatment plans and run reports weekly. The Counselor Supervisor will provide ongoing documentation training to the counseling staff. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of two applicable records. The facility policy and procedure manual indicate a case consultation to occur every three months for the first year of treatment, then annually thereafter.
Client #5 was admitted on October 4, 2023 and transferred from the facility on November 12, 2024. There was no documentation of any case consultations being completed in the client record.
Client #7 was admitted on November 26, 2019 and was still active at the time of the inspection. A case consultation has not been completed since November 9, 2020.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the July 30-31, 2024, March 27, 2024 and August 9, 2023 licensing inspections.
|
Plan of Correction
Counselors have developed spreadsheets which include dates for case consultations. Counselors will complete case consultations every 3 months for the first year of treatment, then annually thereafter. Upcoming case consultation dates are discussed during supervision. Counselors will place holds on patient accounts to ensure that case consultations are completed prior to due date. Counselor Supervisor will monitor timeliness of consultations by utilizing EMR reports of intake dates to track due dates. Counselor Supervisor provided documentation training to the Counseling staff on 1/9/25. |
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 completing case consultations per the facility ' s policy and procedure manual was submitted and approved by the Department for the July 30-31, 2024, March 27, 2024 and August 9, 2023 licensing inspections. Case consultations were again found to be a deficiency in the December 12-13, 2024 licensing inspection.
A plan of correction for the completion of annual clinical evaluations was submitted and approved by the Department for the July 30-31, 2024, March 27, 2024 and August 9, 2023 licensing inspections. The completion of annual clinical evaluations was again found to be a deficiency in the December 12-13, 2024 licensing inspection.
This was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Counselor Supervisor provided documentation training to the counseling staff on January 9, 2025 to address inspection results. The Counselor Supervisor, Counselors and Treatment Center Director are utilizing spreadsheets and checklists to ensure completion of documentation in the appropriate timeframe. The Counselor Supervisor will continue to provide training to the counseling staff and discuss documentation requirements during supervision. The Treatment Center Director and Counselor Supervisor will follow the approved Plans of Correction and ensure that the program is in compliance with state regulations. |