INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 12 - 13, 2022 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:
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of personnel records, the facility failed to document six months of supervision for a counselor assistant with a bachelor ' s degree in one of one applicable personnel record.
Employee #5 was hired as a counselor assistant on June 27, 2022 and was still in the position at the time of the inspection. There was no documentation of supervision notes for July 2022 and September 2022.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 10/24/2022, counselor assistant will be supervised weekly for a period of 6 months through direct supervision by the clinical director and/or the master's level counselor. Whoever is supervising will be responsible for documenting the supervision and placing the note in the employee file. The facility director will monitor employee files to ensure that supervision notes are in the employee records of the counselor assistant. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of administrative documentation and discussion with facility staff, the facility failed to provide CPR certification and First Aid training to a sufficient number of staff persons, so at least one person trained in these skills is onsite during the project's hours of operations.
The facility provided documentation of current CPR certification and First Aid training for one staff member. The employee who is trained in these skills is not at the facility during all hours of operation.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Aces of Hearts, which is a company that holds CPR and first aid training, will conduct a training at the facility by 11/30/2022 to certify all current employees in CPR and first aid. Moving forward, the facility director will make weekly employee schedules to ensure that at least one person trained in these skills is onsite during the facility' hours of operations. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of the facility's January 2022 to September 2022 fire drill log, the facility failed to ensure the written fire drill log included problems encountered and whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 10/24/2022, the written fire drill log was updated by counselor to include problems encountered and whether the smoke detector was operated. These updated forms will be used for all fire drills moving forward. The facility director will monitor fire drill logs to ensure these updated forms are always being used. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the facility's January 2022 to September 2022 fire drill log, the facility failed to ensure the fire alarm, or a smoke detector was set off during the fire drills.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 10/24/2022, counselor revised fire drill logs to include the smoke detector being set off. All fire drills that take place from 10/24/2022 will now include the smoke detector being set off by whatever staff member is conducting the fire drill. The facility director will monitor the fire drill logs to ensure that the smoke detector is always set off during fire drills. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on an administrative review, the project director failed to annually update and sign the written manual delineating the project's policies and procedures.
The project director ' s signature is dated November 3, 2020.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director shall annually update and sign a written manual delineating the project's policies and procedures. A signature page will be added to the policies and procedures manual by counselor by 11/15/2022 to demonstrate compliance with these standards. The project director will sign off on these yearly. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a written procedure for partial hospitalization and outpatient services, which is to include record of service, progress notes, case consultation, and comprehensive treatment plan and discharge summary.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Policies and procedures manual 709.24(3) shall be updated by counselor by 11/15/2022 to include a written procedure for PHP and OP services which include a record of service, progress notes, case consultation, comprehensive treatment plan and discharge summary. The policies and procedures manual will be reviewed by the facility director to ensure proper changes have been made. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on a review of client records and discussion with facility staff, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in four of nine client records. There was no release of information form for the funding source, but disclosure was made.
Client # 1 was admitted to partial hospitalization on June 6, 2022, was transferred to outpatient on July 6, 2022, and was discharged on September 6, 2022.
Client # 5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022.
Client # 7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection.
Client # 10 was admitted to outpatient on August 9, 2022 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 10/24/2022, all clients admitted to the facility will be required to sign a ROI form for their funding source. Client #7 signed form on 10/31/2022. Client #10 will sign the form on his next scheduled session. The facility director will conduct random chart reviews to ensure that all proper ROI forms are in client records. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records and discussions with facility staff, the facility failed to indicate a relevant purpose of the disclosure on release of information forms in four of eight client records.
Release of information forms documented in client records #1, 4, 5 and 7 each indicated three separate purposes of disclosure; continuity of treatment (patient history - case management services), emergency contact - general updates, and court services (legal purposes, Probation, disability claiming, unemployment claiming).
Client #1 was admitted to partial hospitalization on June 6, 2022, was transferred to outpatient on July 6, 2022, and was discharged on September 6, 2022. A release of information form for another agency was signed on June 6, 2022. The purpose of disclosure was not relevant to the agency listed on the release form.
Client #4 was admitted to partial hospitalization on August 30, 2022 and was discharged on September 28, 2022. A release of information form for a medical professional was signed on September 12, 2022. The purpose of disclosure was not relevant to the person listed on the release form.
Client #5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022. Three release of information forms were signed on May 24, 2022. Two forms were for medical professionals, and one form was for an emergency contact. The purpose of disclosure indicated on all three releases was not relevant to the persons listed on the release form.
Client #7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection. Three release of information forms to separate individuals were signed on September 20, 2022. The purpose of disclosure indicated on all three releases was not relevant to the persons listed on the release form.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselor had client #7 sign a new ROI form on 10/31/2022 where the purpose of disclosure is relevant to the person listed on the release form. The facility director will monitor client records and conduct random chart reviews to ensure that a relevant purpose of the disclosure is marked on all ROI's moving forward. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to document a copy of the client consent was offered to the client in ten of ten client records.
Ten of ten client records reviewed included consents. There was no documentation a copy of any of the consents were offered to the client.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
ROI forms were updated by counselor on 11/8/2022 to include that the client was offered a copy of the consent, and whether they accepted or refused. These new forms were updated in the electronic charting system and will be used for all new clients moving forward. All current clients will sign new ROI forms by 11/30/2022. The facility director will review the current client records to ensure that updated ROI forms have been signed by clients. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of client records, the facility failed to document written acknowledgment by clients that the project may not discriminate based on ethnicity, marital status, sexual orientation, and handicap in eight of nine applicable client records.
The written acknowledgement documented in the record at the time of the inspection did not include that the project may not discriminate based on ethnicity, marital status, sexual orientation, and handicap.
Client #1 was admitted to partial hospitalization on June 6, 2022, was transferred to outpatient on July 6, 2022, and was discharged on September 6, 2022.
Client #3 was admitted to outpatient on June 13, 2022 and was discharged July 14, 2022.
Client #4 was admitted to partial hospitalization on August 30, 2022 and was discharged on September 28, 2022.
Client #5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022.
Client #6 was admitted to partial hospitalization on October 4, 2022 and was still active at the time of the inspection.
Client #7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection.
Client #8 was admitted to outpatient on March 30, 2022 and was still active at the time of the inspection.
Client # 10 was admitted to outpatient on August 9, 2022 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client rights forms will be updated in the facility's electronic charting system by counselor by 11/15/2022 to include that the project may not discriminate based on ethnicity, marital status, sexual orientation and handicap. Client's 6, 7, 8, &10 will sign updated forms at the time of their next session. All current clients will sign updated forms by 11/30/2022. The forms will be updated in the electronic charting system therefore all new clients will be signing updated client rights form moving forward. The facility director will review client records to ensure that the updated client rights forms have been signed by all clients. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the clients right to inspect their own records, and the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Eight of nine applicable client records reviewed failed to document written acknowledgement by clients they have been notified of this right.
Client #1 was admitted to partial hospitalization on June 6, 2022, was transferred to outpatient on July 6, 2022, and was discharged on September 6, 2022.
Client #3 was admitted to outpatient on June 13, 2022 and was discharged July 14, 2022.
Client #4 was admitted to partial hospitalization on August 30, 2022 and was discharged on September 28, 2022.
Client #5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022.
Client #6 was admitted to partial hospitalization on October 4, 2022 and was still active at the time of the inspection.
Client #7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection.
Client #8 was admitted to outpatient on March 30, 2022 and was still active at the time of the inspection.
Client # 10 was admitted to outpatient on August 9, 2022 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Policies and procedures manual was updated on 11/4/22 by counselor documenting the procedure for the clients' right to inspect their own records, and the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. Client Rights form shall be updated in the facility's electronic charting system to include this procedure by counselor by 11/15/2022. All new clients admitted to the facility will be signing the updated form moving forward. Clients 6, 7, 8 & 10 and all other current clients will sign updated client rights form by 11/30/2022. The facility director will conduct weekly chart reviews to ensure that all clients are signing proper client's rights form. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the clients right to appeal a decision limiting access to their records to the director.
Eight of nine applicable client records reviewed failed to document written acknowledgement by clients they have been notified of this right.
Client #1 was admitted to partial hospitalization on June 6, 2022, was transferred to outpatient on July 6, 2022, and was discharged on September 6, 2022.
Client #3 was admitted to outpatient on June 13, 2022 and was discharged July 14, 2022.
Client #4 was admitted to partial hospitalization on August 30, 2022 and was discharged on September 28, 2022.
Client #5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022.
Client #6 was admitted to partial hospitalization on October 4, 2022 and was still active at the time of the inspection.
Client #7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection.
Client #8 was admitted to outpatient on March 30, 2022 and was still active at the time of the inspection.
Client # 10 was admitted to outpatient on August 9, 2022 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Policies and procedures manual was updated by counselor on 11/4/2022 to include documentation of a procedure for the clients right to appeal a decision limiting access to their records to the director. Client rights forms will be updated in the facility's electronic charting by counselor by 11/15/2022 to include the procedure for the clients right to appeal a decision limiting access to their records to the director. Moving forward, all new clients will sign this updated form. Clients 6, 7, 8 & 10 and all current clients will sign this updated form by 11/30/2022. The facility director will conduct weekly chart reviews to ensure that all updated client right forms are in client records. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the client ' s right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Eight of nine applicable client records reviewed failed to document written acknowledgement by clients they have been notified of this right.
Client #1 was admitted to partial hospitalization on June 6, 2022, was transferred to outpatient on July 6, 2022, and was discharged on September 6, 2022.
Client #3 was admitted to outpatient on June 13, 2022 and was discharged July 14, 2022.
Client #4 was admitted to partial hospitalization on August 30, 2022 and was discharged on September 28, 2022.
Client #5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022.
Client #6 was admitted to partial hospitalization on October 4, 2022 and was still active at the time of the inspection.
Client #7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection.
Client #8 was admitted to outpatient on March 30, 2022 and was still active at the time of the inspection.
Client # 10 was admitted to outpatient on August 9, 2022 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Policies and procedures manual was updated on 11/4/2022 by counselor to include a procedure for the clients right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. Counselor will update client rights forms by 11/15/2022 in the facility's electronic charting system to include this procedure. Therefore all new clients will sign this updated form moving forward. Clients 6, 7, 8 & 10 and all current clients will sign this updated form by 11/30/2022. The facility director will conduct weekly chart reviews to ensure that clients are signing this updated form to document their acknowledgement of these rights. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
Based on a review of the policy and procedure, the facility failed to document a procedure for the client ' s right to submit rebuttal data or memoranda to their own records
Eight of nine applicable client records reviewed failed to document written acknowledgement by clients they have been notified of this right.
Client #1 was admitted to partial hospitalization on June 6, 2022, was transferred to outpatient on July 6, 2022, and was discharged on September 6, 2022.
Client #3 was admitted to outpatient on June 13, 2022 and was discharged July 14, 2022.
Client #4 was admitted to partial hospitalization on August 30, 2022 and was discharged on September 28, 2022.
Client #5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022.
Client #6 was admitted to partial hospitalization on October 4, 2022 and was still active at the time of the inspection.
Client #7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection.
Client #8 was admitted to outpatient on March 30, 2022 and was still active at the time of the inspection.
Client # 10 was admitted to outpatient on August 9, 2022 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Policies and procedures manual was updated by counselor on 11/4/2022 to include a procedure for the client's right to submit rebuttal data or memoranda to their own records. Client rights forms will be updated by counselor by 11/15/2022 to include this procedure in the facility's electronic charting system. Therefore all new clients will be signing this updated form moving forward. Clients 6, 7, 8, & 10 and all current clients will sign this updated form by 11/30/2022 to document written acknowledgement of these rights. The facility director will conduct weekly chart reviews to ensure that this updated form is being signed off on by all clients. |
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.
|
Observations
Based on a review of client records, the facility failed to assure partial hospitalization clients are provided individual counseling services at least twice a week in four of four client records.
Client # 1 was admitted to partial hospitalization on June 6, 2022 and was transferred to outpatient on July 6, 2022. The record of service and progress notes indicated that only three individual counseling sessions occurred between June 6, 2022 and July 6, 2022. Individual counseling services were not provided at least twice a week for client #1.
Client # 4 was admitted to partial hospitalization on August 30, 2022 and was discharged on September 28, 2022. The record of service and progress notes indicated that only three individual counseling sessions occurred between August 30, 2022 and September 28, 2022. Individual counseling services were not provided at least twice a week for client #4.
Client # 5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022. The record of service and progress notes indicated that only two individual counseling sessions occurred between May 24, 2022 and June 30, 2022. Individual counseling services were not provided at least twice a week for client #5.
Client # 7 was admitted to partial hospitalization on September 20, 2022 and was still active at the time of the inspection. The record of service and progress notes indicated that only three individual counseling sessions occurred between September 20, 2022 and the inspection. Individual counseling services were not provided at least twice a week for client #7.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Master's level counselor will be responsible for conducting individual counseling services at least twice a week for PHP clients from 11/14/2022 and moving forward. The facility director will monitor the counselor to ensure that all required sessions are occurring weekly. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to provide a complete client record which includes follow-up information in one of one applicable client record.
Client # 5 was admitted to partial hospitalization on May 24, 2022 and was discharged on June 30, 2022. There was no follow-up information documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility will provide a complete client record which includes follow information for client #5 by 11/14/2022. The client's primary counselor will be responsible for contacting and documenting the follow up with this client. The facility director will conduct weekly chart reviews to ensure that client records are complete with follow up information. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to provide a complete client record which includes follow-up information in one of two applicable client records.
Client # 2 was transferred into the outpatient level of care on July 6, 2022 and was discharged on September 6, 2022. There was no follow-up information documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility will provide a complete client record which includes follow information for client #2 by 11/14/2022. The client's primary counselor will be responsible for contacting and documenting the follow up with this client. The facility director will conduct weekly chart reviews to ensure that client records are complete with follow up information. |