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, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, MedMark Treatment Centers of Pennsylvania d/b/a MedMark Treatment Centers of 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to document the qualifications for the position of project director based on a review of personnel records during the annual licensing inspection conducted on August 7 - 8, 2017.
Employee # 1 became the project director on October 26, 2016. No educational/experiential qualifications were documented for the project director.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will submit the Project Director's qualifications to the Department to review by 10/31/17. The Governing Body will ensure that any employee selected for the position of Project Director will meet the educational/experiential qualifications for the position. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that each female patient prescribed buprenorphine was fully informed of the possible risks to her or her unborn child in one of three patient records reviewed during the annual licensing inspection conducted on August 7 - 8, 2017.
Patient # 6 was admitted into treatment on December 15, 2016 and discharged on June 26, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the staff meeting, held on 8/9/17, the contents of the intake packet was reviewed to ensure that the "Child Bearing Consent" was present in both the methadone and buprenorphine intake packets. The Clinical Supervisors will ensure that this form is in place when conducting random chart audits. |
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
The facility failed to document a random urinalysis for each patient receiving methadone treatment in three of nine patient records reviewed during the annual licensing inspection conducted on August 7 - 8, 2017.
Patient # 10 was admitted on October 21, 2016 and discharged on April 14, 2017. A monthly drug screen was not documented for February 2017.
Patient # 14 was admitted on January 31, 2017 and discharged on June 25, 2017. A monthly drug screen was not documented for February 2017.
Patient # 15 was admitted on March 31, 2016 and discharged on April 27, 2017. A monthly drug screen was not documented for January 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy on monthly drug screens was reviewed with the nursing staff on 8/16/17. The nurses were also trained on how to capture patients who were not given a urine drug screen test before month's end, so they can obtain one and maintain compliance. The Lead Nurse will ensure compliance when conducting random, monthly chart audits. |