INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11th - 14th, 2018 of Pocono Mountain Recovery Center by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Pocono Mountain Recovery Center 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based upon a review of personnel records, and a review of the educational and experiential documentation for clinical staff, the facility failed to ensure that all staff hired as counselors met the qualifications for the position.
Employee # 4 was hired as a counselor on August 6, 2018; however, the individual's educational degree did not meet the requirements for the position of a counselor.
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Plan of Correction
Employee #4's had given her two weeks' notice prior the survey and is no longer with the agency.
With future hires for the counselors position. The Clinical Director along with the HR Director will determine that any counselor employed at PMRC will have valid credentialing and education within the requirements stipulated by the Commonwealth of Pennsylvania. All prospective candidates for the position of counselor will meet the Pennsylvania requirements to be a counselor prior to being hired for that specific position, and these credentials will be corroborated with the Pennsylvania Certification Board or the appropriate licensing agency and educational institution.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The soffit in the front of the building facing the parking lot had sections that were worn and cracked, exposing visible holes/gaps that would allow for additional water damage and enable access for rodents and insects.
These findings were reviewed with facility staff.
Based on a physical plant inspection, the gate which prevents people from falling off of the loading dock was observed to be latched open. The loading dock is one floor off of the ground.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance and kitchen staff retrained on 12/17/2018 on proper closing and locking of loading dock gate. Supervisor of maintenance responsible for ongoing monitoring of gate and ensuring it remains closed when not in use.
Materials to repair damage soffit purchased on 1/4/2019 repair scheduled for 1/9/2019.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, it was observed that the dumpster lids were warped leaving an opening large enough for the penetration of insects and rodents to enter the container.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Refuge contractor was contacted on 12/17/18 and a new dumpster was supplied.
To prevent this from reoccurring the maintenance supervisors will inspect the dumpster weekly and report to operations director and clinical director his findings. If needed dumpster will be replaced on a regular basis.
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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on a physical plant inspection conducted on 12/11/18, a dresser in Room 16 was missing a drawer. Maintenance staff corrected the deficiency by adding the missing drawer on 12/14/18.
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Plan of Correction
To ensure as not to have a reoccurring problem, all furniture will be inspected by tech staff daily and by maintenance supervisor weekly. Any issue will be reported to director of operations and clinical director and will be addressed / repaired immediately to ensure patient storage. |
705.5 (k) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(k) Bedrooms located in a basement shall meet the following requirements:
(1) The bedroom shall have wall, floor and ceiling coverings such as tile, linoleum, paneling or dry wall.
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Observations
During a physical plant inspection conducted on 12/11/18, Room 27 was observed to have a fist sized hole in the dry wall. Upon further review additional areas in Room 26 showed caving ceilings concerns as well as missing/chipped paint along the paneling of exterior walls between the bathroom and bedroom.
These findings were reviewed with facility staff during the inspection.
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Plan of Correction
All repairs observed and addressed have been completed on 1/4/2019. Ongoing supervision of facility, buildings, and sleeping accommodations will be done by supervisor of maintenance and any necessary repairs will be reported to Director of Operations and addressed immediately. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
A physical plant inspection was conducted at the facility on 12/11/18. During the inspection of the bathrooms in Rooms 4, 6, 7 showers were observed not to have slip-resistant surfaces in all bathtubs and showers.
These findings were reviewed with the facility staff during the inspection.
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Plan of Correction
Non-slip surfaces have been installed in all patient showers on 1/4/2019. Presences of non-slip shower surfaces will be monitored by maintenance supervisor. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on 12/11/18 the facility failed to Maintain each bathroom in a functional, clean and sanitary manner at all times. Inside of Room 25 mold was observed on the bathroom ceiling located above the bathtub. Water damage was observed between where the drywall and tub meet. Wood molding along the bathtub floor displayed warping and appeared to be affected by water damage as well.
These findings were reviewed with facility staff during the inspection.
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Plan of Correction
All repairs and remediation have been completed on 1/4/2019. Exhaust fans have been installed in all rooms where they were not previously installed.
Ongoing supervision of facility, buildings, and sleeping accommodations will be done by supervisor of maintenance and any necessary repairs will be reported to Director of Operations and addressed immediately. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to store silverware in an enclosed area.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility purchased and installed new silverware enclosure on 1/7/2019 where silverware will be properly stored at all times. Proper storage of silverware will be monitored by the Head Chef to ensure ongoing compliance. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to store all food items off the floor. In the small room adjacent to the kitchen which has items for the soda and juice machines, unopened boxes of juice and soda syrup were observed sitting on the floor.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility failed to follow its procedure for proper storage of food and food related items. Facility has modified its procedure for receiving deliveries on 12/17/2018. All delivery items will be delivered to loading dock. Dietary aide will be responsible for storing items insuring they are stored off of them floor. All kitchen staff trained on updated procedure on 12/17/2018. Proper storage procedure will be monitored by the Head Chef to ensure ongoing compliance. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
The facility failed to maintain two exits on every floor including the attic in the Detox building. Additionally, the facility lacked smoke detectors and a fire extinguisher in the attic. All detection devices shall be interconnected.
These findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
Fire Extinguisher installed on 1/7/2019.
Facility has drafted an exception request pertaining to the attic and submitted for review.
In the interim, access will be restricted, no items will be stored in this area. If the request for exception is not granted, facility will comply with the standard in its entirety.
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant inspection, it was observed that the dumpster lids were warped leaving an opening large enough for the penetration of insects and rodents to enter the container.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Refuge contractor was contacted on 12/17/18 and a new dumpster was supplied.
To prevent this from reoccurring the maintenance supervisors will inspect the dumpster weekly and report to operations director and clinical director his findings. If needed dumpster will be replaced on a regular basis.
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705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
The facility failed to maintain two exits on every floor including the basement and attic in the Freedom House. Additionally, the facility lacked smoke detectors and a fire extinguisher in the attic. All detection devices shall be interconnected.
These findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
Fire Extinguisher installed on 1/7/2019.
Facility has drafted an exception request for the pertaining to the basement and submitted for review.
In the interim, access will be restricted, no items will be stored in this area. If the request for exception is not granted, facility will comply with the standard in its entirety.
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705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
During a physical site inspection of the outpatient building titled Freedom House on 12/11/18, it was noted that the interior stairway going to the second floor had no secured handrail from the landing to the second floor. The original handrail was embedded into the wall. Facility maintenance staff did correct this by adding a secured handrail before the end of the inspection on 12/14/18.
These findings were discussed with facility staff at the time of the inspection.
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Plan of Correction
This was corrected on 12/11/2018.
Ongoing supervision of facility, buildings, and sleeping accommodations will be done by supervisor of maintenance and any necessary repairs will be reported to Director of Operations and addressed immediately.
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705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
During a physical plant inspection conducted on 12/11/18, The facility failed to ensure that there were smoke detectors in the attic of the outpatient building Freedom House. All detection devices shall be interconnected.
These findings were reviewed with facility staff who indicated that they would draft an exception request as the attic is only utilized for storage
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Plan of Correction
Fire Extinguisher installed on 1/7/2019.
Facility has drafted an exception request pertaining to the attic and submitted for review.
In the interim, access will be restricted, no items will be stored in this area. If the request for exception is not granted, facility will comply with the standard in its entirety.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to adequately document to whom information was to be released on the Authorization to Disclose Healthcare form in one client record.
Client #1 was admitted on May 7, 2018 and discharged on August 1, 2018. On the Authorization to Disclose Healthcare consent form, the facility listed the person to receive information as "Jimmy" and "Supervisor" failing to document adequately to whom the information should be released to.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members will be educated on confidentiality and the importance of completing a release of information for any third party agency that includes EAP, Probation, and Supervisors. This training will be completed by 1/11/2019 and will continue monthly.
Monthly training will include how to properly complete a release of information. Weekly audits will be conducted to ensure proper paperwork are completed upon completion of initial evaluation.
The clinical director and director of compliance will responsible for training and ensuring staff understand the proper paperwork necessary.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to properly document information that is permitted to be released on a consent form in accordance with 4 Pa. Code 255.5 (b).
Client #1 was admitted on May 7, 2018 and discharged on August 1, 2018. On an Authorization to Disclose Healthcare consent form, dated May 7, 2018, information released to "Human Resources Director" permitted disclosure of a discharge summary, discharge instructions, verbal report of psychological evaluation/diagnostic summary and "to coordinate efforts with family and/or concerned persons".
Client #4 was admitted on July 25, 2018 and discharged October 1, 2018. On an Authorization to Disclose Healthcare consent form, dated July 26, 2018, information released to "Probation" permitted disclosure of a verbal report of pscyhological evaluation/diagnostic summary". An Authorization to Disclose Healthcare consent form to "Northampton County Adult Probation" permitted disclosure of a discharge summary.
Client #9 was admitted on September 30, 2018 and was active at the time of the inspection. On an Authorization to Disclose Healthcare consent form, dated September 30, 2018, information released to "Probation" permitted disclosure of a verbal report of pscyhological evaluation/diagnostic summary".
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff members' staff will be educated on confidentiality and PA.255.5 the importance of knowing what can be released to outside agency's completing a release of information for any third party agency. This training will be completed by 1/11/2019
Monthly training will include how to properly complete a release of information. Weekly audits will be conducted to ensure proper paperwork is being released.
The clinical director and director of compliance will responsible for training and ensuring staff understand the proper paperwork necessary and that can be released under PA 255.5.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to document medication administration in accordance with physician's orders.
Client #4 was admitted on July 25, 2018 and discharged on October 1, 2018. On July 27, 2018, the client's 8:00am dose for Prozac 20mg PO daily was not documentated in the medication administration record as being given. In addition, on August 6, 2018 at 9:00pm, the client's Bactroban 2% ointment to be used on open wounds TID until healed was not documented as applied. The client received the ointment from July 28, 2018 through August 10, 2018. There was no documentation of client refusing either medication.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 1/1/2019 each nurse prior to the end of their shift will review MAR and address any inconsistencies. Nursing supervisor and/or Director of Nursing will review administration record weekly to ensure ongoing compliance. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of five residential clients on a buprenorphine detox regiment, the facility failed to properly document nursing assessments and verbal orders in accordance with Licensing Alert 04-12 dated May 2012, in two of the client records. The alert states a nursing assessment must be completed by at minimum a registered nurse. In addition, if verbal orders at given, only a single dose, or a dose divided in two, may be ordered verbally, and the verbal dose may not exceed 8mg.
Client #2BD was admitted on May 11, 2018 and was discharged on August 10, 2018. In the absence of a physician, a nursing assessment was completed by a LPN on May 11, 2018 at 10:20pm. The verbal orders given on May 12, 2018 at 12:22am was for a complete six day taper regiment starting with a first dose of Subutex 16mg SL.
Client #5BD was admitted on September 18, 2018 and discharged on October 8, 2018. In the absence of a physician, a nursing assessment was completed by a LPN on September 18, 2018 at 4:30pm. The verbal orders given on September 18, 2018 at 6:50pm was for a complete six day taper regiment starting with a first dose of Subutex 16mg SL.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients will be seen and assessed by physician prior to ordering or administering of narcotic. This assessment will document patients appropriateness for administration of narcotic. In the absence of the physician, facility will adhere to guidelines outlined in Licensing Alert 04-12 dated May 2012. Director of Nursing and Quality Review Coordinators will review charts daily to ensure procedure is being followed. Any deviation will be reported to CEO for immediate intervention. |