Observations
Based on a review of personnel records, the facility failed to ensure that one applicable employee received a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum within the regulatory timeframe
Employee #5 has been in the position of counselor since September 3, 2024 and was current in that position at time of licensing process. Employee # 5 was due to have the communicable disease training no later than September 3, 2025; however, the HIV/AIDS training was not completed until January 14, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the finding:
- Employee #5 completed the required HIV/AIDS training on January 14, 2026 using a Department-approved curriculum.
- The certificate of completion was placed in the employee's personnel file.
- The Training Coordinator reviewed all personnel files to verify communicable disease training compliance for all staff.
- No additional staff were found to be out of compliance.
The deficiency occurred due to:
1. The staff was signed up for a HIV training that was cancelled and never rescheduled.
2. This training was part of his training plan for the training year, however did not specifically indicate that he needed to take the training in 1st quarter.
Corrective Actions
In January 2026, the Executive Director found this training on-demand on the PA train website. The staff took it within 24 hours of finding this available training and staff was trained prior to site visit. The Executive Director is more familiar with on demand trainings available which are easier to control the date of training.
All of our staff are fully trained at this time with all of the core trainings required by licensing. In the future, new hires will be documented time limits of when they need to take the trainings upon hire. The staff will have a copy of this and ultimately the Executive Director will follow up when creating training plans being aware of the dates when the training is required.
Since this issue was addressed prior to licensing, there is nothing further Recovery Revolution is able to do at this moment to correct this action.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of seven records reviewed.
Client # 1 was admitted October 20, 2025 and discharged January 16, 2026. The treatment plan completed on November 26. 2025, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that any individual sessions were offered the week of December 14, 2025.
Client # 5 was admitted on September 19, 2025 and was active at the time of the licensing inspection. The treatment plan completed on October 15, 2025, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that any individual sessions were offered during the weeks of November 10, 2025, December 8, 2025, January 12, 2026, and January 26, 2026.
Client # 7 was admitted on August 14, 2025 and was active at the time of the licensing inspection. The treatment plan completed on September 12, 2025, indicated that the client was to receive two group sessions per week; however, the record did not contain documentation that a second group session was offered the weeks of September 22, 2025, September 29, 2025, October 13, 2025, October 20, 2025, and November 3, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon notification of the findings, the Clinical Director conducted a full chart review for Clients #1, #5, and #7 to understand the issue.
The deficiency occurred due to the following factors:
1. Inconsistent documentation practices between counselors when sessions were rescheduled, refused, or missed.
2. Documentation that was available was on billing sheets, which is not part of the chart and therefore appears like gaps in service.
In response, Recovery Revolution has implemented the following corrective actions:
1. All clinical staff will schedule every client that they were scheduled to see that week, no matter the status according to the prescribed treatment plan frequence. They will then address all of their clients to state reason for not showing.
2. As a secondary check, on Friday, our case manager will review the entire week's schedule in our EMR system and address anyone on the schedule who has not been "Checked In" The process of checking in and stating a reason for not showing automatically generates the progress note.
3. If our case manager finds that there are not a clinician following this, she will report directly to the clinical director. Non-compliance will result in:
- Immediate corrective supervision
- Retraining
- Progressive discipline if repeated
There will be an all staff training on February 24, 2026 at 2 pm to describe the new protocol to address the citation.
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