INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 27, 2024 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 Perryopolis 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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #6 received the minimum of at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #6 was hired as a counselor assistant on July 18, 2022 and was due to have the communicable disease trainings no later than July 18, 2023; however, the employee did not receive the required training until October 12, 2023. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The director will ensure that counselors and counselor assistants will complete the required training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. The director will keep updated personnel records with training records for each staff member. The director reviewed training requirements with staff members, 03/13/2023.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to complete random urinalysis at least monthly in one of eight patient records. Patient # 6 was admitted on October 10, 2019 and was discharged on July 18, 2023. There was no documentation of a urinalysis done in May 2023.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
MedMark Treatment Centers Perryopolis will ensure completion of an initial drug test urinalysis for each patient and a random urinalysis at least monthly thereafter. The facility will use SAMMs program for monthly randomization/selection of patients to provide urinalysis testing. The medical team will audit patient charts to ensure all patients receive monthly urinalysis testing; commencing 03/22/2024 The director reviewed the deficiency with the treatment team and plan of care, 03/13/2024 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of five applicable records. The facility's policy and procedures manual states a psychosocial evaluation is to be completed within five days of admission.Client #3 was admitted on September 5, 2023 and was still active at the time of the inspection. A psychosocial evaluation was not completed until October 13, 2023. Client #5 was admitted on November 27, 2023 and was discharged on December 21, 2023. At the time of the inspection no psychosocial evaluation was documented in the client record. Client #8 was admitted on July 26, 2023 and was discharged on August 9, 2023. At the time of the inspection, no psychosocial evaluation was documented in the client record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The treatment center director re-educated the clinical team, 03/13/2024,about the policy concerning psychosocial evaluation
The clinical team will complete the psychosocial evaluation within five days of admission. The clinical team will keep track of due dates for psychosocial evaluation using a spreadsheet and SAMMs program holds/reminders; commencing 03/22/2024. |
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:
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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 one out of two applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within 30 days following admission.Client #1 was admitted on June 30, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 30, 2023; however, the comprehensive treatment plan was not completed until August 7, 2023. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The director re-educated the clinical team on the policy concerning comprehensive treatment plans, 03/13/2024. The comprehensive treatment plan will be completed within 30 days following admission. The clinical team will keep track of due dates for comprehensive treatment plans using a spreadsheet and SAMMs program holds/reminders; commencing 03/22/2024. |
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 within the regulatory timeframe in five out of five applicable client records reviewed.Client #1 was admitted on June 30, 2023 and was still active at the time of the inspection. A treatment plan update was completed on December 6, 2023 and the next update was due no later than February 6, 2024; however, no update was documented in the client record at the time of the inspection. Client #3 was admitted on September 5, 2023 and was still active at the time of the inspection. A treatment plan update was completed on November 3, 2023 and the next update was due no later than January 3, 2023 ; however, it was completed on February 16, 2024. Client #4 was admitted on May 23, 2018 and was still active at the time of the inspection. A treatment plan updated was completed on October 26, 2023 and the next update was due no later than December 26, 2023; however, it was completded on January 23, 2024. Client #6 was admitted on October 10, 2019 and was discharge July 18, 2023 . A treatment plan update was completed on April 10, 2023 and the next update was due no later than June 10, 2023; however, no update was documented in the client record at the time of the inspection.Client #7 was admitted on June 2, 2019 and was discharged September 8, 2023 . A treatment plan update was completed on March 22, 2023 and the next update was due no later than May 22, 2023; however, it was not completed until June 2, 2023.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director re-educated the clinical team on the policy concerning comprehensive treatment plans, 03/13/2024. The comprehensive treatment plan will be completed every 60 days for active clients. The clinical team will keep track of due dates for comprehensive treatment plans using a spreadsheet and SAMMs program holds/reminders; commencing 03/22/2024. |
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.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in three out of five applicable records reviewed. The facility's policy and procedures manual states a case consultation is to be completed every three months within the first year and yearly after.Client #1 was admitted on June 30, 2023 and was still active at the time of the inspection. A case consultation would be due by September 30, 2023; however, there was none documented in the record at the time of the inspection. Client #3 was admitted on September 5, 2023 and was still active at the time of the inspection. A case consultation was due on December 5, 2023; however, there was none documented in the record at the time of the inspection. Client #4 was admitted on May 23, 2018 and was still active at the time of the inspection. A case consultation was due May 23, 2023; however, there was none documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director re-educated the clinical team on the policy concerning case consultation, 03/13/2024. The case consults will be completed every 90 days within the first year of treatment. The clinical team will keep track of due dates for case consults using a spreadsheet and SAMMs program holds/reminders; commencing 03/22/2024. |
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 provide a complete client record, which is to include follow-up information in two out of four discharged records reviewed.Client #5 was admitted on November 27, 2023 and was discharged on December 21, 2023Client #8 was admitted on July 26, 2023 was discharged on August 9, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MedMark Treatment Centers Perryopolis clinical treatment team will complete a post discharge follow up at 7 days for each patient identified to be discharged commencing Friday 3/22/2024. Clinical team will keep track of documents due at discharge by following a discharge checklist. The supervisor will complete chart audits to ensure discharge documents are completed. The facility director reviewed this process with clinical team and supervisor Monday, 3/13/2024, and documented the review in employees' record. |