INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2024 through October 18, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lewis Recovery, LLC - Victory Park 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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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 the review of eight personnel records and staff training records, the project failed to instruct all staff in the use of the fire extinguisher upon employment.Employee #7 was hired as a counselor on January 15, 2024, and was to have instruction on the use of the fire extinguisher upon employment; however, the employee was not instructed on the use of the fire extinguisher until February 7, 2024.Employee #8 was hired as the counselor on January 2, 2024, and was to have instruction on the use of the fire extinguisher upon employment; however, the employee was not instructed on the use of the fire extinguisher until January 31, 2024.This is a repeat citation from the November 14, 2024, annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to 705.28 (c) (4), employees #7 and #8 completed use fire extinguisher training on 11/12/2024. Leadership reviewed onboarding documentation and have included Fire Extinguisher Training in onboarding documentation packet. HR will review all new hire onboarding and will report to leadership when onboarding is complete for all new employees. CCO and CD will ensure fire extinguisher instruction completion upon hire and during the onboarding process. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of seven personnel records and staff training records, the project failed to ensure that two personnel are trained to perform assigned tasks during emergencies upon working a shift.Employee #7 was hired as a counselor on January 15, 2024, and was to be trained to perform assigned tasks during emergencies upon working a shift; however, the employee did not receive this training until February 7, 2024.Employee #8 was hired as a counselor on January 2, 2024, and was to be trained to perform assigned tasks during emergencies upon working a shift; however, the employee did not receive this training until January 31, 2024.This is a repeat citation from the November 14, 2024, annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
It was found that employees #6 and #7 were not trained upon hire and they were trained in January of 2024. Pursuant to 705.28 (d) (3), Leadership will meet monthly to review all new hires and ensure necessary training has been completed. Upon hiring of new employees, the employee will be trained to perform assigned tasks during emergencies. HR will review all new hire documentation utilizing New Hire Checklist in each employee's HR file. HR will report to CFO and CD of any outstanding training and/or documentation to ensure all new staff is trained appropriately.
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709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on the review of the policy and procedure manual, the project failed to develop written procedures for the management of treatment/rehabilitation services for clients that included timeframes on the completion of client case consultations.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CCO revised the facility's Policies and Procedures to address lack of timeframes regarding case consultations.
Leadership discussed the revision which stated that "case consolations will be complete for each client prior to discharge."
Case consultations were added to EMR system and all clinical staff has been updated and trained on case consultations, the timeframe outlined in the Policies and Procedures and how to initiate the form in EMR system as of 11/4/2024.
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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 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 that included the name of the person, agency or organization to whom disclosures will be made to in two of fourteen records reviewed. Client #6 was admitted on May 8, 2024, and was discharged on September 3, 2024. A release of information form, signed by the client on May 8, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.Client #12 was admitted on August 27, 2024, and was discharged on October 1, 2024. A release of information form, signed by the client on August 27, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.This is a repeat citation from the November 14, 2024, annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.28 (c) (1)
It was found that in the client records for discharged clients #6 and #12, informed and voluntary consents were blank and signed by the client. Pursuant to regulation 709.28(c)(1), Admission Director and CCO reviewed informed and voluntary consents. Admissions Director will audit all new client intakes informed and voluntary consents and remove any consents that are left blank from the client record. CCO and Admissions Director will review any informed and voluntary consents that are blank to ensure that the consent is in fact invalid and will be removed from client record. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on the review of partial hospitalization client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in three of seven records reviewed.Client #9 was admitted on August 22, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on August 27, 2024, and the update was due no later than September 27, 2024; however, there was no updated plan documented in the record at the time of the licensing inspection.Client #11 was admitted on February 22, 2024, and was discharged on April 9, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on February 29, 2024, and the update was due no later than March 29, 2024; however, there was no updated plan documented in the record at the time of the licensing inspection.Client #13 was admitted on April 16, 2024, and was discharged on June 10, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on April 23, 2024, and the update was due no later than May 23, 2024; however, there was no updated plan documented in the record at the time of the licensing inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CD and CCO met with treatment team and conducted treatment planning training identifying deficiencies ini regulation 709.82(b).
Clinical staff was educated on the 30 day treatment plan update timeframes for each level of care. CD will conduct the weekly treatment team meeting and will have staff report treatment plan updates for the week and which clients have upcoming updates. Clinical staff was also advised to open treatment plans during every session for quality of care and to update treatment plan if needed. Clinical staff was also trained on EMR system to schedule alerts for treatment plan update.
Client #9 was met with and treatment plan was reviewed.
Client #11 and #13 were discharged clients and unable to complete a treatment plan update. |
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 the review of client records, the project failed to document two weekly individual counseling sessions in three of seven partial hospitalization clients reviewed.Client #11 was admitted on February 22, 2024, and was discharged on April 9, 2024. The project only documented one individual counseling session for the weeks of March 17, 2024 through March 23, 2024 and March 31, 2024 through April 6, 2024. Additionally, there were no individual counseling sessions documented for the week of March 10, 2024 through March 16, 2024.Client #12 was admitted on August 27, 2024, and was discharged on October 1, 2024. The project only documented one individual counseling session for the weeks of September 8, 2024 through September 14, 2024 and September 22, 2024 through September 28, 2024.Client #13 was admitted on April 16, 2024, and was discharged on June 10, 2024. The project only documented one individual counseling session for the weeks of April 21, 2024 through April 27, 2024, April 28, 2024 through May 4, 2024, May 5, 2024 through May 11, 2024, May 19, 2024 through May 25, 2024 and May 26, 2024 through June 1, 2024. Additionally, there were no individual counseling sessions documented for the week of May 12, 2024 through May 18, 2024.This is a repeat citation from the November 14, 2024, annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
It was found that discharged clients #11, #12 and #13 did not have individual sessions nor documentation of a missed service.
CD and CCO met with the clinical staff for treatment planning training and reviewed regulation 709.82(d)(1). Clinical staff were advised that any sessions need to be documented and any missed services also need to be documented noting the reason for the missed service.
CD will conduct a weekly chart audit to ensure that all services have been documented including missed services. |
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.
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Observations
Based on the review of partial hospitalization client records, the project failed to document a complete client record on an individual that included follow-up contact notes in four of four applicable client records reviewed.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CCO and CD met with clinical staff to review deficiency 709.83(a)(11). Primary Therapists are tasked with making follow up contact with discharged clients within 90 days of discharged. This will be documented in the discharged client's EMR chart.
CD will keep log of discharged clients and will audit discharge charts once a month to ensure contact notes have been completed and documented. |
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.
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Observations
Based on the review of outpatient client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in three of seven records reviewed.Client #3 was admitted on March 12, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan was documented in the record on March 27, 2024, and the update was due no later than May 27, 2024; however, a treatment plan update was not documented in the record until June 11, 2024.Client #4 was admitted on March 8, 2024, and was discharged on July 3, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on March 13, 2024, and the update was due no later than May 13, 2024; however, a treatment plan update was not documented in the record until June 7, 2024.Client #6 was admitted on May 8, 2024, and was discharged on September 3, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on May 13, 2024, and the update was due no later than July 13, 2024; however, a treatment plan update was not documented in the record until August 1, 2024.This is a repeat citation from the November 14, 2024, annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CD and CCO met with treatment team and conducted treatment planning training identifying deficiencies ini regulation 709.92(b).
Clinical staff was educated on the treatment plan update timeframes for each level of care, specifically for outpatient records. CD will conduct the weekly treatment team meeting and will have staff report treatment plan updates for the week and which clients have upcoming updates. Clinical staff was also advised to open treatment plans during every session for quality of care and to update treatment plan if needed. Clinical staff was also trained on EMR system to schedule alerts for treatment plan update.
CD also met with the primary therapist for client #3, #4 and #6 to review deficiency and ensure compliance to regulation 709.92(b). Clients #4 and #6 were discharged and unable to complete treatment plan update.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed.Client #2 was admitted on August 19, 2024, and was a current client at the time of the licensing inspection. An initial treatment and rehabilitation plan, documented in the client record on August 19, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of September 8, 2024 through September 14, 2024, September 15, 2024, through September 21, 2024, September 22, 2024 through September 28, 2024 and October 6, 2024 through October 12, 2024.Client #3 was admitted on March 12, 2024, and was a current client at the time of the licensing inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 27, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the week of September 15, 2024, through September 21, 2024.Client #4 was admitted on March 8, 2024, and was discharged on July 3, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on March 13, 2024, indicated that the client was to receive two individual counseling session per week; however, the project only documented one individual counseling session for the weeks of March 17, 2024 through March 23, 2024. Additionally, there were no individual counseling sessions documented for the week of March 31, 2024 through April 6, 2024.Client #6 was admitted on May 8, 2024, and was discharged on September 3, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on May 13, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of July 14, 2024 through July 20, 2024, July 21, 2024 through July 27, 2024 and August 18, 2024, through August 24, 2024.Client #7 was admitted on February 26, 2024, and was discharged on July 11, 2024. A comprehensive treatment and rehabilitation plan, documented in the client record on March 5, 2024, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the weeks of May 19, 2024 through May 25, 2024, May 26, 2024 through June 1, 2024, June 2, 2024 through June 8, 2024, June 9, 2024 through June 15, 2024, June 16, 2024 through June 22, 2024 and June 30, 2024 through July 6, 2024.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
It was found that discharged clients #2, #3, #4, #6 and #7 did not have individual sessions nor documentation of a missed service.
CD and CCO met with the clinical staff for treatment planning training and reviewed regulation 709.92(c). Clinical staff were advised that any sessions need to be documented and any missed services also need to be documented noting the reason for the missed service.
CD will conduct a weekly chart audit to ensure that all services have been documented including missed services. CD met with primary therapist for clients #2 and #3 to ensure that any sessions or missed sessions are to be documented in the client's chart. Clients #4, #6 and #7 were discharged and deficiency was reviewed with the primary therapists. |
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 the review of outpatient client records, the project failed to document a complete client record on an individual that included case consultation notes in three of three applicable client records reviewed.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to regulation 709.93(a)(8), CCO revised Policies and Procedures to include case consultations to be completed "prior to discharge."
CCO and CD had EMR system add a Case Consultation form to be completed by clinical staff for each client.
CD will conduct chart audits to ensure that case consultations are being completed. |
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.
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Observations
Based on the review of outpatient client records, the project failed to document a complete client record on an individual that included follow-up contact notes in four of four applicable client records reviewed.This is a repeat citation from the November 14, 2024, annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CCO and CD met with clinical staff to review deficiency 709.83(a)(11). Primary Therapists are tasked with making follow up contact with discharged clients within 90 days of discharged. This will be documented in the discharged client's EMR chart.
CD will keep log of discharged clients and will audit discharge charts once a month to ensure contact notes have been completed and documented.
CD and CCO will meet monthly to review all follow up documentation for discharged clients to ensure this deficiency is not repeated. |