INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 10, 2024 through September 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Armada Recovery PA, 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
|
704.11(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.
|
Observations
Based on a review of administrative documents, the project director failed to develop an assessment of staff training needs.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The agency has developed and trained staff on revised policy and procedures, which document training plans and related content that must be completed both upon hire and annually. The Director of HR will be responsible for ensuring that all training plans are part of the personnel folders; the project Director shall review supervision notes and training plans monthly. The HR Director and Project Director will monitor this corrective action activity by inspecting personnel folders, via the checklist and inspecting supervision activity, (notes, training plans, perf. evals. monthly |
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.
|
Observations
Based on a review of administrative documents, the project director failed to develop an overall plan for addressing staff training needs.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The agency has developed and trained staff on revised policy and procedures, which document training plans and related content that must be completed both upon hire and annually. The overall agency training plan will consist of focus on confidentiality, ASAM criteria, stages of change, disease prevention, relapse prevention, and evidenced based therapy. Necessary DDAP trainings will be prioritized for all new staff within the first year of hire by the Clinical Director, and subsequently overall training plans will be in accordance with state regulations. Needs for trainings will be reassessed and addressed monthly by Clinical Director. |
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.
|
Observations
Based on the review of five personnel records, the project failed to document an individual training plan for three employees within the first 30-days of employment.
Employee #1 was hired on September 12, 2023, and was to have an individual training plan documented by October 11, 2023; however, there was no training plan documented in the personnel record.
Employee #3 was hired on December 4, 2023, and was to have an individual training plan documented by January 3, 2024; however, there was no training plan documented in the personnel record.
Employee #4 was hired on August 14, 2024, and was to have an individual training plan documented by September 13, 2024; however, there was no training plan documented in the personnel record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The agency has developed and trained staff on revised policy and procedures, which document training plans and related content that must be completed both upon hire and annually. The Director of HR will be responsible for ensuring that all training plans are part of the personnel folders; the project Director shall review supervision notes and training plans monthly. The HR Director and Project Director will monitor this corrective action activity by inspecting personnel folders, via the checklist and inspecting supervision activity, (notes, training plans, perf. evals. monthly |
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 the review of the fire drill log from October 2023 through August 2024, the facility failed to maintain written fire drill records that included exit routes used, the number of people in the facility at the time of the drill and whether the fire alarm or smoke detector was operative.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Project Director will keep detailed record of monthly fire drills. This recordkeeping started in September 2024 and will continue under the supervision of the Project Director. Fire drills will be performed monthly and record will be kept of time, place, evacuation point, and personnel present. The Clinical Director/Project Director will create the monthly fire drill log and will update with date, item, 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. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on a review of administrative documents, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with project staff during the licensing process.
|
Plan of Correction
CEO and CCO will obtain the services of an independent certified public accountant for an annual financial audit. They will submit report for review for 2024 and every year subsequently. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of fourteen client records reviewed.
Client #4 was admitted on April 2, 2024, and was discharged on April 24, 2024. Prior to the client ' s discharge, the client was referred to another treatment facility. A release of information form for the other treatment facility was not documented in the client record prior to the disclosure.
Client #5 was admitted on July 5, 2024, and was discharged on July 23,2024. A release of information form for the funding source was not documented in the client record; however, the facility verified billing had occurred.
Client #7 was admitted on June 14, 2024, and was discharged on July 29,2024. A release of information form for the funding source was not documented in the client record; however, the facility verified billing had occurred.
Client #8 was admitted on June 24, 2024, and was a current client at the time of the licensing inspection. A release of information form for the funding source was not documented in the client record; however, the facility verified billing had occurred.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The agency has revised its intake/admissions paperwork to include Release of Information forms for supervising agencies and insurance carriers, in addition to family, and/or friends. The Project Director/Clinical Director will ensure the completion of this citation by reviewing all new admits to ensure adherence. Client #8 was no longer a client when POC was reviewed and submitted. All future clients will have the necessary releases and any other documentation signed. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client #11 was admitted on March 28, 2024 and was involuntarily discharged on June 24, 2024. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Our termination policy has been revised to include the following: any proposed discharges will be presented to the Project Director prior to discharge. At the time a decision is made to administratively discharge a client the client will be notified verbally and provided a written notice of the discharge grievance and appeal processes. The Project Director shall be responsible for ensuring that any clients administratively discharged receive written notice of their discharge and all related information. |
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.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of the seven client records reviewed.
Client # 1 was admitted on April 22, 2024, and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on April 30, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on August 22, 2024, and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 26, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on August 30, 2024, and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on August 30, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on April 2, 2024, and was discharged on April 24, 2024. The individual treatment and rehabilitation plan completed on April 11, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on July 5, 2024, and was discharged on July 23, 2024. The individual treatment and rehabilitation plan completed on July 12, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on May 21, 2024, and was discharged on June 19, 2024. The individual treatment and rehabilitation plan completed on June 4, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on June 14, 2024, and was discharged on July 29, 2024. The individual treatment and rehabilitation plan completed on June 17, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Master Treatment Plan will be completed within 30 days of treatment. To ensure compliance with this policy the Clinical Director/Project Director will conduct monthly audits of charts, additionally clients will be reviewed in a bi-monthly multidisciplinary meeting. Treatment plans will describe the frequency and type of treatment and rehabilitations services. |
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 the review of client records, the project failed to document two weekly individual counseling sessions in five of seven partial hospitalization clients reviewed.
Client # 1 was admitted on April 22, 2024, and was active at the time of the inspection. The project failed to document any individual counseling sessions for the weeks of July 22, 2024 through July 26, 2024 and August 12, 2024 through August 16, 2024. The project only documented one individual counseling session for the weeks of May 20, 2024 through May 24, 2024, May 27 through May 31, 2024, June 3, 2024 through June 7, 2024, June 10, 2024 through June 14, 2024, August 5, 2024 through August 9, 2024, August 19, 2024 through August 23, 2024, August 26, 2024 through August 30, 2024 and September 2, 2024 through September 6, 2024.
Client # 2 was admitted on August 22, 2024, and was active at the time of the inspection. The project failed to document one individual counseling session for the weeks of August 26, 2024 through August 30, 2024 and September 2, 2024 through September 6, 2024.
Client # 5 was admitted on July 5, 2024, and was discharged on July 23, 2024. The project failed to document one individual counseling session for the weeks of August 8, 2024 through August 12, 2024 and August 15, 2024 through August 19, 2024.
Client # 6 was admitted on May 21, 2024, and was discharged on June 19, 2024. The project failed to document one individual counseling session for the weeks of May 27, 2024 through May 31, 2024, June 3, 2024 through June 7, 2024, and June 10, 2024 through June 14, 2024.
Client # 7 was admitted on June 14, 2024, and was discharged on July 29, 2024. The project failed to document one individual counseling session for the weeks of June 17, 2024 through June 21, 2024, June 24 through June 28, 2024, July 1, 2024 through July 5, 2024 and July 15, 2024 through July 19, 2024.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinicians will document two weekly individual counseling sessions in PHP program. Each PHP client will have one individual session in the first half of the week and one in the second half of the week, and updates on changes and LOC needs will be relayed by clinicians during weekly supervision. Clinicians will contact clients as frequently as possible in the event that they must miss sessions due to illness etc, and these contacts will be documented in the weekly summary note. This will be overseen and verified by the Clinical Director/Project Director. |
709.83(a)(4) 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:
(4) Case consultation notes.
|
Observations
Based on the review of partial hospitalization client records, the project failed to document a complete client record on an individual that included case consultation notes, per facility policy, in five of seven client records reviewed. The facility policy documents that case consultations will be completed at admission, step-down, step-up and for critical safety issues.
Client # 1 was admitted on April 22, 2024, and was active at the time of the inspection. There was no documentation of case consultation notes in the client record.
Client # 2 was admitted on August 22, 2024, and was active at the time of the inspection. There was no documentation of case consultation notes in the client record.
Client # 3 was admitted on August 30, 2024, and was active at the time of the inspection. There was no documentation of case consultation notes in the client record.
Client # 5 was admitted on July 5, 2024, and was discharged on July 23, 2024. There was no documentation of case consultation notes in the client record.
Client # 6 was admitted on May 21, 2024, and was discharged on June 19, 2024. There was no documentation of case consultation notes in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The staff has been educated on the agencies "Case Consultation" policy has been reviewed with all staff to ensure compliance with our policy following admission the person completing the admission will present the client to the treatment team in our morning consultation meeting to the treatment team. The policy has been updated to say that will hold a morning briefing meeting daily to review admissions, potential discharges, and any other pertinent information on the treatment population. The Project Director, in the absence of a Clinical Director, will be responsible for ensuring consultation notes are placed in the client folder, this will be monitored by monthly chart audits and weekly team meetings. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of the seven client records reviewed.
Client # 8 was admitted on June 24, 2024, and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on June 31, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 9 was admitted on April 9, 2024, and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on April 16, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 10 was admitted on January 22, 2024, and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on February 6, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 11 was admitted on March 28, 2024, and was discharged on June 24, 2024. The individual treatment and rehabilitation plan completed on April 3, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 12 was admitted on April 14, 2024, and was discharged on June 11, 2024. The individual treatment and rehabilitation plan completed on April 22, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 13 was admitted on May 6, 2024, and was discharged on July 24, 2024. The individual treatment and rehabilitation plan completed on May 14, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 14 was admitted on May 8, 2024, and was discharged on July 8, 2024. The individual treatment and rehabilitation plan completed on May 14, 2024 did not include documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Master Treatment Plan will be completed within 30 days of treatment. To ensure compliance with this policy the Clinical Director/Project Director will conduct monthly audits of charts, additionally clients will be reviewed in a bi-monthly multidisciplinary meeting. Clinical Director will monitor all aspects of the initial treatment plan and any subsequent updates, including type and frequency. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in five of seven client records reviewed.
Client # 8 was admitted on June 24, 2024, and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on June 21, 2024 and the update was due no later than August 21, 2024; however, the updated plan was not documented in the record until September 6, 2024.
Client # 9 was admitted on April 9, 2024, and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan was documented in the record on April 16, 2024 and the update was due no later than June 16, 2024; however, the updated plan was not documented in the record until August 8, 2024.
Client # 10 was admitted on January 22, 2024, and was active at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on March 20, 2024 and the next update was due no later than May 20, 2024; however, there was no updated plan documented in the record at the time of the inspection.
Client # 11 was admitted on March 28, 2024, and was discharged on June 24, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on April 3, 2024 and the next update was due no later than June 3, 2024; however, there was no updated plan documented in the record at the time of the inspection.
Client # 13 was admitted on May 6, 2024, and was discharged on July 24, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on May 14, 2024 and the next update was due no later than July 14, 2024; however, there was no updated plan documented in the record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Master Treatment Plan will be completed within 30 days of treatment. To ensure compliance with this policy the Clinical Director/Project Director will conduct monthly audits of charts, additionally clients will be reviewed in a bi-monthly multidisciplinary meeting. Any client treatment plans that need to be updated will be noted for the corresponding clinician, and Clinical Director will follow up with the clinician until treatment plan is updated. Updates will be made to treatment plans at least every 60 days. |
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.
|
Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included case consultation notes, per facility policy, in three of seven client records reviewed. The facility ' s policy indicates that case consultations will be completed at admission, step-down, step-up, and for critical safety issues.
Client # 9 was admitted on April 9, 2024, and was active at the time of the inspection. Case consultation notes were not documented in the client record.
Client # 12 was admitted on April 14, 2024, and was discharged on June 11, 2024. Case consultation notes were not documented in the client record.
Client # 13 was admitted on May 6, 2024, and was discharged on July 24, 2024. Case consultation notes were not documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The staff has been educated on the agencies "Case Consultation" policy has been reviewed with all staff to ensure compliance with our policy following admission the person completing the admission will present the client to the treatment team in our morning consultation meeting to the treatment team. The policy has been updated to say that will hold a morning briefing meeting daily to review admissions, potential discharges, and any other pertinent information on the treatment population. The Project Director, in the absence of a Clinical Director, will be responsible for ensuring consultation notes are placed in the client folder, this will be monitored by monthly chart audits and weekly team meetings. |