INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pittsburg Recovery Center 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative records, the facility failed to ensure an assessment of staff training needs was completed within the time frame set by the facility.
The facility ' s policy and procedures state that an assessment of staff training needs shall begin during the last week of December of every year. The facility provided an assessment of staff training needs dated for July 24, 2023. The facility did not complete an assessment of staff training needs within the time frame of their policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By December 15, 2023 the project director shall ensure an assessment of staff training needs is completed. This will be following the time frame set forth in the facility's policies and procedures. Moving forward, by December 15, each and every year, the project director will ensure that an assessment of training needs is completed. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative records, the facility failed to ensure that an overall plan for addressing training needs was completed within the time frame set by the facility.
The facility ' s policy and procedure states an overall plan for addressing training needs is due to be in place by January 15th of every year. The facility provided an overall plan for addressing these needs dated for July 24, 2023. The facility did not complete an overall plan for addressing training needs within the time frame of their policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By January 15, 2024, the project director will ensure that an overall plan for addressing training needs is completed and documented. This will be following the time frame set forth in the facility's policies and procedures. Moving forward, by January 15, each and every year, the project director shall ensure that an overall plan for addressing training needs is completed and documented. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative records and staff interview, the facility failed to ensure that a mechanism to collect feedback on completed training was completed according to the facility ' s policies and procedures.
The facility ' s policies and procedures state that a questionnaire has been developed and will be distributed during each training and collected and the end of each training. No such questionnaire on completed trainings was found in any staff record. Staff interview also confirmed that no such questionnaire had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/22/2023, the lead counselor created a form for employees to fill out upon completion of any training. This form is to collect feedback on completed trainings. Upon completion every training, employees will fill out this form. They will then submit this form to the lead counselor. This form will then be placed in each individual employee's record. The project director will monitor the employee files to ensure all proper documentation is in place. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative records, the facility failed to ensure an annual evaluation of the overall training plan was completed within the time frame set by the facility.
The facility ' s policies and procedures state that the annual evaluation of the overall training plan will take place each year during the entire month of December. The facility provided an evaluation of the overall training plan dated for July 24, 2023. The facility did not complete an annual evaluation of the overall training plan within the time frame of their policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By December 31, 2023, the project director shall ensure that an annual evaluation of the overall training plan is completed. This will be following the time frame set forth in the facility's policies and procedures. By December 31 of every year, the project director will be responsible for ensuring that an annual evaluation of the overall training plan is completed. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff records, the facility failed to ensure a written individual training plan was developed for each employee in six of six records.
Staff #1 was hired to the position of Project Director on January 3, 2022 and was in this position at the time of review. Staff #1 ' s record did not contain a written individual training plan.
Staff #2 was hired on July 24, 2023 to the position of Clinical Supervisor and was in this position at the time of review. Staff #2 ' s record did not contain a written individual training plan.
Staff #3 was hired January 3, 2022 to the position of counselor and was in this position at the time of review. Staff #3 ' s record did not contain a written individual training plan.
Staff #4 was hired June 5, 2023 to the position of counselor and was in this position at the time of review. Staff #4 ' s record did not contain a written individual training plan.
Staff #5 was hired April 24, 2023 to the position of counselor and was in this position at the time of review. Staff #5 ' s record did not contain a written individual training plan.
Staff #6 was hired January 23, 2023 to the position of counselor and was in this position at the time of review. Staff #6 ' s record did not contain a written individual training plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon hire of any new employee, the project director shall develop an individual training plan for each employee, appropriate to that employee's skill level. This will be documented and placed in the employee's file. On 8/7/2023, the project director formed individual training plans with staff # 2,3,4,5 and 6 for the rest of the fiscal year. These were documented and placed in each individual employee's files. Staff #1 IS the project director. He will be responsible for getting his training hours and ensuring all proper documentation is in his and all other employee files. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of staff records, the facility failed to ensure that all staff were instructed in the use of the fire extinguisher upon staff employment in three of four records.
Staff #4 was hired on June 5, 2023 to the position of counselor and was in this position at the time of review. Staff #4 ' s record contained documentation of completion of instruction in the use of the fire extinguisher on July 3, 2023. Staff #4 was not instructed in the use of the fire extinguisher upon staff employment.
Staff #5 was hired on April 24, 2023 to the position of counselor and was in this position at the time of review. Staff #5 ' s record contained documentation of completion of instruction in the use of the fire extinguisher on July 3, 2023. Staff #5 was not instructed in the use of the fire extinguisher upon staff employment.
Staff #6 was hired on January 23, 2023 to the position of counselor and was in this position at the time of review. Staff #6 ' s record contained documentation of completion of instruction in the use of the fire extinguisher on July 3, 2023. Staff #6 was not instructed in the use of the fire extinguisher upon staff employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/29/2023 and moving forward, upon hire, any new employees will immediately be instructed in the use of the fire extinguisher, on their start date. This will be documented and placed in employee files. The project director will monitor the employee files to ensure that all proper documentation is in place. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of staff records, the facility failed to ensure an annual written individual staff performance evaluation, which is reviewed and signed by the employee, was completed in one of one record.
Staff #3 was hired to the position of counselor on January 3, 2022 and was in this position at the time of review. Staff #3 ' s record did not contain an annual written individual staff performance evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By December 31, 2023, the project director shall conduct annual written individual staff performance evaluations for each employee. Also, Staff #3 annual performance evaluation was unavailable and not provided during the inspection process. This form was located and documented in Staff #3's employee file on 8/16/2023. The project director will monitor employee files to ensure that all proper documentation is in place. Moving forward, every year, by December 31, the project director will be responsible for conducting annual written individual staff performance evaluations for every employee. The project director will document these and place them in employee files. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 ensure that an individual treatment plan includes proposed type and frequency of treatment and rehabilitation services in three of six records.
Client #10 was admitted to the partial hospitalization level of care on July 25, 2023 and was active at the time of review. Client #10 ' s record contained a comprehensive treatment and rehabilitation plan dated August 1, 2023. This treatment and rehabilitation plan did not include a proposed type and frequency of treatment and rehabilitation services.
Client #11 was admitted to the partial hospitalization level of care on May 12, 2023 and was discharged June 22, 2023. Client #11 ' s record contained a comprehensive treatment and rehabilitation plan dated May 25, 2023. This treatment and rehabilitation plan did not include a proposed type and frequency of treatment and rehabilitation services.
Client #13 was admitted to the partial hospitalization level of care on July 10, 2023 and was active at the time of review. Client #13 ' s record contained a comprehensive treatment and rehabilitation plan dated July 17, 2023. This treatment and rehabilitation plan did not include a proposed type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/3/2023, the lead counselor corrected client #10 and client #13's treatment plans to include a proposed type and frequency of treatment and rehabilitation services. Moving forward, the lead counselor will be responsible for monitoring all client files to ensure that the treatment plans include the proposed type and frequency of treatment and rehabilitation services. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure partial hospitalization clients are provided individual counseling services at least twice a week in five of five client records.
Client #8 was admitted to the partial hospitalization level of care on June 19, 2023 and was active at the time of review. The record of service and progress notes indicated only one individual counseling session occurred for the weeks of June 26, July 10, July 17, and July 24, 2023. The record of service and progress notes indicated no individual counseling sessions occurred for the week of July 3, 2023. Individual counseling services were not provided at least twice a week for client #8.
Client #9 was admitted to the partial hospitalization level of care on June 26, 2023 and was active at the time of review The record of service and progress notes indicated only one individual counseling session occurred for the weeks of July 3, July 10, and July 24, 2023. The record of service and progress notes indicated no individual counseling sessions occurred for the week of July 17, 2023. Individual counseling services were not provided at least twice a week for client #9.
Client #11 was admitted to the partial hospitalization level of care on May 12, 2023 and was discharged June 22, 2023. The record of service and progress notes indicated only one individual counseling session occurred for the weeks of May 22 and May 29, 2023. The record of service and progress notes indicated no individual counseling sessions occurred for the week of May 15 and June 12, 2023. Individual counseling services were not provided at least twice a week for client #11.
Client #12 was admitted to the partial hospitalization level of care on April 10, 2023 and was discharged May 15, 2023. The record of service and progress notes indicated only one individual counseling session occurred for the weeks of May 1 and May 8, 2023. Individual counseling services were not provided at least twice a week for client #12.
Client #13 was admitted to the partial hospitalization level of care on July 10, 2023 and was active at the time of review The record of service and progress notes indicated only one individual counseling session occurred for the week of July 17, 2023. The record of service and progress notes indicated no individual counseling sessions occurred for the week of July 24, 2023. Individual counseling services were not provided at least twice a week for client #13.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 12-13, 2022 annual licensing inspection and the March 23, 2023 provisional licensing inspection.
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Plan of Correction
On 8/21/2023, the full time PHP counselor assumed the responsibility for ensuring that individual counseling occurs twice weekly for all PHP clients. He will also be responsible for documenting these individual sessions. The lead counselor will be responsible for monitoring the client records to ensure that the individual counseling sessions are taking place and being documented. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included documentation of disclosure of criteria for admission, treatment, completion and discharge to the client in three of seven records.
Client #1 was admitted to the outpatient level of care on May 31, 2023 and was active at the time of review. Client #1 ' s record did not include documentation that they were informed of criteria for admission, treatment, completion and discharge.
Client #3 was admitted to the outpatient level of care on June 13, 2023 and was active at the time of review. Client #3 ' s record did not include documentation that they were informed of criteria for admission, treatment, completion and discharge.
Client #5 was admitted to the outpatient level of care on May 4, 2023 and was discharged July 25, 2023. Client #5 ' s record did not include documentation that they were informed of criteria for admission, treatment, completion and discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/31/2023, Client # 1 and their primary counselor will sign the Admission Orientation Checklist, documenting the client's acknowledgement of the disclosure of criteria for admission, treatment, completion and discharge to the client. Client #3 and #5 have been discharged and this error cannot be corrected in their charts. This was due to an error that occurred within the facility's EMR. Moving forward, the lead counselor will be responsible for monitoring all admission forms to ensure that the client signs acknowledgement of the disclosure of criteria for admission, treatment, completion and discharge. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included documentation of client orientation to the project which includes a familiarization with project polices in three of seven records.
Client #1 was admitted to the outpatient level of care on May 31, 2023 and was active at the time of review. Client #1 ' s record did not include documentation of a client orientation to the project which includes a familiarization with project policies.
Client #3 was admitted to the outpatient level of care on June 13, 2023 and was active at the time of review. Client #3 ' s record did not include documentation of a client orientation to the project which includes a familiarization with project policies.
Client #5 was admitted to the outpatient level of care on May 4, 2023 and was discharged July 25, 2023. Client #5 ' s record did not include documentation of a client orientation to the project which includes a familiarization with project policies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/31/2023, Client #1 and their primary counselor will sign the Admission Orientation Checklist, documenting the acknowledgement of the client's orientation to the project and includes a familiarization with the project's policies. Client #3 and #5 have been discharged and this error cannot be corrected in their charts. This was due to an error that occurred within the facility's EMR and was an oversight within the facility. Moving forward, the lead counselor will be responsible for monitoring all admission forms to ensure that there is documentation of client orientation to the project that includes familiarization with the project policies. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included documentation of client orientation to the project which includes a familiarization with the hours of operation in three of seven records.
Client #1 was admitted to the outpatient level of care on May 31, 2023 and was active at the time of review. Client #1 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the hours of operation.
Client #3 was admitted to the outpatient level of care on June 13, 2023 and was active at the time of review. Client #3 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the hours of operation.
Client #5 was admitted to the outpatient level of care on May 4, 2023 and was discharged July 25, 2023. Client #5 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/31/2023, Client #1 and their primary counselor will sign the Admission Orientation Checklist, documenting the acknowledgement of the client's orientation to the project which includes a familiarization with the hours of operation. Client #3 and #5 have been discharged and this error cannot be corrected. This was due to an error that occurred within the facility's EMR and was an oversight within the facility. Moving forward, the lead counselor will be responsible for monitoring all admission forms to ensure that there is documentation of client orientation to the project which includes familiarization with the hours of operation. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included documentation of client orientation to the project which includes a familiarization with the fee schedule in three of seven records.
Client #1 was admitted to the outpatient level of care on May 31, 2023 and was active at the time of review. Client #1 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the fee schedule.
Client #3 was admitted to the outpatient level of care on June 13, 2023 and was active at the time of review. Client #3 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the fee schedule.
Client #5 was admitted to the outpatient level of care on May 4, 2023 and was discharged July 25, 2023. Client #5 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the fee schedule.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/31/2023, Client #1 and their primary counselor will sign the Admission Orientation Checklist, documenting the client's acknowledgement of a familiarization with the fee schedule (if any.) Client #3 and #5 have been discharged and this error cannot be corrected. This was due to an error that occurred within the facility's EMR and was an oversight within the facility. Moving forward, the lead counselor will be responsible for monitoring all admission forms to ensure that there is documentation of client orientation to the project which includes familiarization of the fee schedule. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to ensure intake procedures included documentation of client orientation to the project which includes a familiarization with the services provided in three of seven records.
Client #1 was admitted to the outpatient level of care on May 31, 2023 and was active at the time of review. Client #1 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the services provided.
Client #3 was admitted to the outpatient level of care on June 13, 2023 and was active at the time of review. Client #3 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the services provided.
Client #5 was admitted to the outpatient level of care on May 4, 2023 and was discharged July 25, 2023. Client #5 ' s record did not include documentation of a client orientation to the project which includes a familiarization with the services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/31/2023, Client #1 and their primary counselor will sign the Admission Orientation Checklist, documenting the client's acknowledgement of a familiarization with the services provided. Client #3 and #5 have been discharged and this error cannot be corrected. This was due to an error that occurred within the facility's EMR and was an oversight within the facility. Moving forward, the lead counselor will be responsible for monitoring all admission forms to ensure that there is documentation of client orientation to the project which includes familiarization to the services provided. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |
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 ensure the client record contained case consultation notes in two of two records.
Client #6 was admitted to the outpatient level of care April 10, 2023 and was discharged August 1, 2023. Facility policy states that a case consult is to be done every 90 days. A case consultation note for client #6 was due on or before July 10, 2023. No case consultation note was found in client #6 ' s record.
Client #7 was admitted to the outpatient level of care January 9, 2023 and was discharged July 11, 2023. Facility policy states that a case consult is to be done every 90 days. A case consultation note for client #7 was due on or before April 7, 2023. No case consultation note was found in client #7 ' s record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges that it failed to document case consults for clients #6 and #7. Both client's are discharged and this error cannot be corrected. This was due to the EMR not containing a form for case consults. These forms were being documented as a Word document then scanned to the client files. This was an oversight by the facility. As of 8/14/2023, the project director created a case consult form directly within the EMR. The lead counselor will be responsible for ensuring that all case consults take place and are documented in the client records when any client is at the same level of care for 90 days. The project director will conduct weekly chart reviews to ensure that all proper documentation, including case consults, are in the client record. |
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.
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Observations
Based on a review of client records, the facility failed to comply with plans of corrections that were approved by the Department.
Plans of correction for ensuring partial hospitalization clients are provided individual counseling services at least twice a week were submitted and approved by the Department for the October 12-13, 2022 annual licensing inspection and the March 23, 2023 provisional licensing inspection. Ensuring partial hospitalization clients are provided individual counseling services at least twice a week was again found to be a deficiency in the August 2, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges that it failed to comply with plans of corrections previously submitted to the department and did not ensure that PHP clients were provided individual counseling services at least twice per week. This was due, in part, to the previous PHP counselor resigning from their position. The facility has filled this position with a new full-time PHP therapist as of 8/21/2023. There should be no more errors regarding this matter in the future. The full time PHP counselor will be responsible for providing individual counseling services at least twice per week and documenting these sessions. The lead counselor will be responsible for monitoring client records to ensure that the individual sessions are taking place and being documented correctly. The project director will also conduct weekly chart reviews to ensure that all proper documentation is in place in the client records. |