INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28 - 29, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resolution Recovery Center LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel training records, the facility failed to document HIV/AIDS training in one of one record.
Employee # 1 has been in the position of project director since July 1, 2019. No documentation of HIV/AIDS training was provided for employee # 1.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 attended and successfully completed an approved DDAP 7-hour HIV/AIDS Awareness and Prevention Class. Certificate was presented to employee #1 and will be kept in employee #1 file.
Training calendar to be completed, updated and maintained by Employee #1.
Program Director to ensure that all employees of Resolutions Recovery Center have an up-to-date yearly training calendar. This calendar will include information that all necessary trainings are completed by all staff with the required timeframes by utilizing a form to track training due dates for all clinical and support staff.
All successfully completed training certificates will be kept in the employee's file. |
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.
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Observations
Based on a review of staff schedules, training certificates and an interview with the project/facility director, the project failed to document CPR certification and first aid training for a sufficient number of staff persons, so that at least one person trained in these skills was available during the project's hours of operation.
The facility provides residential treatment twenty-four hours per day, seven days per week.
No staff with CPR certification and first aid training were onsite during the following dates and times:
March 21 - 22, 2022, March 25 -28, 2022, April 2 - 5, 2022, April 8 - 12, 2022, April 15 - 18, 2022 and April 20 - 24, 2022 - 11 PM - 6 AM
No staff with CPR certification were onsite during the following dates and times:
March 23 - 24, 2022, March 29 - April 1, 2022, April 6 - 7, 2022, April 13 - 14, 2022 and April 19, 2022 - 11 PM - 6 AM
April 23, 2022 - 8 AM - 11 AM
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director to have employees not trained in CPR and first aid attend training, to receive certifications. All employees to be scheduled for CPR and first aid training. This will ensure that all shifts will have one or more CPR and first aid certified staff member on shift.
Training calendar will include CPR and first aid training. Certification will be kept in staff file. Training calendar will include expiration dates of CPR and first aid trainings to ensure recertification will take place in the correct timeframe.
New hirers, if not already CPR or first aid certified with be scheduled during their orientation period to complete the CPR and first aid training.
All employees that do not currently have a CPR or first aid certification will attend and complete a DDAP certified CPR and first aid course by the end of June 2022.
Program Director will ensure at least one staff person with CPR certification and first aid training will be scheduled 24 hours a day, 7 days per week.
Program Director will ensure training is completed by all staff within the required timeframes by utilizing the training calendars.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of March 2021 through March 2022 fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every six months.
The facility's sleeping hours are from 11:30 PM through 6 AM. The only fire drill conducted during sleeping hours was in October 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A fire drill during sleeping hours will be conducted on 5/24/2022. The next facility sleeping fire drill is scheduled for August of 2022.
Program Director will ensure a fire drill during sleeping hours is conducted at least every 6 months. The Program Director will ensure a fire drill during sleeping hours that will be an unannounced drill. Program Director will ensure that these fire drills are documented in the fire drill log. The deficiency will be corrected as of 5/24/2022.
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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.
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Observations
Based on a review of administrative materials and an interview with the project/facility director, the project failed to document a financial audit for the July 1, 2020 through June 30, 2021 fiscal year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Completing the yearly fiscal audit is a certified public accountant business.
There is an assigned CPA accountant to Resolutions Recovery Center's account. CPA to work with Program Director to ensure compliance, dates and times are met for reporting purposed to DDAP and local SCA.
Independent certified public accountant business will conduct the financial audit for RRC in August of 2022. Estimated time of completion of the financial audit October 2022. This will be a full financial audit as requested by local SCA and DDAP regulations. The dates pertaining to the full financial audit will be 7/01/2021 through 6/30/2022. The local SCA requires the audit to be complete and turned in by November 1, 2022. Resolutions Recovery Center will comply with all timelines.
Program Director will keep and provide detailed records of audit information for the DDAP and local SCA.
Yealy audits will be scheduled and completed for each fiscal year for RRC.
July 1, 2020, through June 30, 2021, audit Program Director will request an exception from the DDAP and if denied Program Director will obtain and audit for this time period. |
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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent for the disclosure of information contained in the client record in seven of seven records.
The facility released client urine samples for drug testing during the intake process without the written consent of the client or a qualified service organization agreement with the laboratory in the following records:
Client # 1 was admitted March 22, 2022.
Client # 2 was admitted April 5, 2022.
Client # 3 was admitted March 18, 2022.
Client # 4 was admitted November 10, 2021 and discharged December 29, 2021.
Client # 5 was admitted November 19, 2021 and discharged December 30, 2021.
Client # 6 was admitted November 3, 2021 and discharged January 14, 2022.
Client # 7 was admitted December 7, 2021 and discharged February 1, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Director corrected, updated and completed the written informed and voluntary consent. The consent to release information form completed will meet DDAP requirements. Corrections made, the consent to release urine samples from drug testing during the intake process was completed. Clients to be presented with release for signature during the intake process.
Deficiency does not occur again, the correction, update and new completed consent to release information was completed on 4.29.2022.
Resolutions Recovery Center to add the correct release consent during intake process. Staff were educated on the new consent to release information form.
A qualified service organization agreement to be completed by Resolutions Recovery Center and laboratory. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document a consent to release information form that included the date, event or condition upon which the consent will expire in seven of seven records.
The following records contained consents that were documented during the intake process and did not include the date, event or condition upon which the consent will expire:
Client # 1 was admitted March 22, 2022. Consents were documented for probation and funding.
Client # 2 was admitted April 5, 2022. Consents were documented for probation, courts, public defender and funding.
Client # 3 was admitted March 18, 2022. Consents were documented for probation and funding.
Client # 4 was admitted November 10, 2021 and discharged December 29, 2021. Consents were documented for probation and funding.
Client # 5 was admitted November 19, 2021 and discharged December 30, 2021. A consent was documented for funding.
Client # 6 was admitted November 3, 2021 and discharged January 14, 2022. Consents were documented for funding.
Client # 7 was admitted December 7, 2021 and discharged February 1, 2022. Consents were documented for an attorney, probation, courts and funding.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Director corrected, updated and completed the consent to release information form to meet DDAP requirements. Corrections made, the consent to release information form now includes the date, event or condition upon which the consent will expire.
Deficiency does not occur again, the correction, update and new completed consent to release information was completed on 4.29.2022.
To ensure compliance the incorrect release consent forms were removed from circulation in the Resolutions Recovery Center office and the correct release consent was added. Staff were educated on the new consent to release information form.
Clinical Director will conduct random chart audits to ensure consents utilized include the expiration. |
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.
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Observations
Based on a review of client records and the client handbook, the facility failed to document a copy of a client consent was offered to the client in seven of seven records.
The following records contained consents that were documented during the intake process and did not include documentation as to whether a copy of the consent was offered to the client:
Client # 1 was admitted March 22, 2022. Consents were documented for probation and funding.
Client # 2 was admitted April 5, 2022. Consents were documented for probation, courts, public defender and funding.
Client # 3 was admitted March 18, 2022. Consents were documented for probation and funding.
Client # 4 was admitted November 10, 2021 and discharged December 29, 2021. Consents were documented for probation and funding.
Client # 5 was admitted November 19, 2021 and discharged December 30, 2021. A consent was documented for funding.
Client # 6 was admitted November 3, 2021 and discharged January 14, 2022. Consents were documented for funding.
Client # 7 was admitted December 7, 2021 and discharged February 1, 2022. Consents were documented for an attorney, probation, courts and funding.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Director corrected, updated and completed the consent that a client was offered a copy of the consent during the intake process. Correction, signatures and check boxes added to the consent for client to sign to indicate they were offered and received a copy of the information.
Deficiency does not occur again, the correction, update and new completed consent to release information was completed on 4.29.2022.
To ensure compliance the incorrect release consent forms were removed from circulation in the Resolutions Recovery Center office and the correct release consent was added. Staff were educated on the new consent to release information form.
Clinical Director will conduct random chart audits to ensure the consents utilized indicate a copy was offered to the client. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an inspection of the medication storage area and an interview with the project/facility director, the facility failed to document a quarterly inspection of the medication storage area from March 2021 through March 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director, Medical Director and Head of Nursing developed a medication storage checklist that will be completed monthly by the medical staff. Program director will ensure the checklist is being followed. The monthly nursing check list includes:
Monthly inventory of medications and inspection of medication storage areas.
All medications will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security with adequate storage space to ensure drug potency and to inhibit degradation.
Drugs requiring special conditions for storage are stored in a refrigerator capable of maintaining the necessary temperatures. Review the daily recorded temperature of the refrigerator to check for ranges. Proper destruction and disposal of medications. Outdated drugs are properly disposed. All drugs are kept in locked and some in double locked storage. The medication room door is closed and locked when not in use. All poisons, external drugs, and internal drugs are stored on separate shelves or in separate containers. Copies of drug-related regulations are available in appropriate areas
The nursing checklist was implemented on 4/29/2022. The nursing checklist log will be kept in the nursing area. Reviewed by Medical Director and Program Director. |
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.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project in one of one record.
Client # 5 was admitted November 19, 2021 and involuntarily terminated from treatment December 30, 2021.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Program Director and Clinical Director corrected, updated and completed the letter, written notification of the decision to involuntarily terminate the client's treatment. Corrections made, the letter, written notification will be given to the client or mailed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment.
Deficiency does not occur again, the correction, update and new completed letter, written notification was completed on 4.29.2022.
To ensure compliance the written, letter notification form was presented to the staff. Staff were educated on the new letter, written notification form.
Clinical Director will conduct closed chart audits to ensure the client was notified of the decision to involuntarily terminate their treatment at Resolutions Recovery Center and the reason for this termination. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records and the client handbook, the facility failed to notify the client of their opportunity to request reconsideration of the decision terminating treatment in one of one record.
Client # 5 was admitted November 19, 2021 and involuntarily terminated from treatment December 30, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Clinical Director corrected, updated and completed the letter, written notification that a client has the opportunity to request reconsideration of the decision of being terminated from treatment. Corrections made, the letter, written notification will be given to the client or mailed to notify the client, that the client has the opportunity to request reconsideration of the decisions of being terminating treatment.
Deficiency does not occur again, the correction, update and new completed letter, written notification was completed on 4.29.2022.
To ensure compliance the written, letter notification form was presented to the staff. Staff were educated on the new letter, written notification form.
Clinical Director will conduct random closed chart audits to ensure the client was notified of their right to request reconsideration of the decisions terminating their treatment at Resolutions Recovery Center. |