INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Cove LLC 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's January 2023 through December 2023 training year in one of one applicable personnel records reviewed.
Employee #2 was hired as a counselor on September 12, 2022. The personnel record had documentation that only 6.25 hours of annual training were obtained during the reviewed training year.
This finding was reviewed with facility staff as part of the licensing process.
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Plan of Correction
Program Director reviewed with counselor on 4/3/2024 trainings hours for each year is 25 hours. Program director and counselor created an action plan with different training sites and prioritizing trainings for 2024. Program Director will review progress during monthly supervisions. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of seven applicable client records reviewed.
Client #8 was admitted to the outpatient activity on December 22, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on December 26, 2023 and did not include the type and frequency of treatment and rehabilitation services to be provided to the client.
Client #10 was admitted to the outpatient activity on November 20, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on November 30, 2023 and did not include the type and frequency of treatment and rehabilitation services to be provided to the client.
Client #11 was admitted to the outpatient activity on January 9, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on January 23, 2024 and did not include the type and frequency of treatment and rehabilitation services to be provided to the client.
This is a repeat citation from the April 28, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/8/2024 during group supervision, Program Director reviewed Treatment plans with clinical team to identify frequency and type of services. Program Director provided examples for clinical team and treatment plan shall identify LOC, Frequency and type in objectives. Program Director will review all initial and change of LOC when completed. Program Director will complete monthly audits to ensure treatment plans are compliant. |