INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21-24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pocono Mountain 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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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 on January 23, 2020, 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 beverages were observed sitting on the floor.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 14, 2018 inspection.
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Plan of Correction
The Facility failed to follow its procedure for proper storage of food and food related items. Going forward one of the Dietary Aides will be responsible for storing items, ensuring they are stored off the floor. All kitchen staff will be trained on 2/26/20. Proper storage procedure will be monitored by Head Chef and quality Assurance will be conducting a monthly inspection to ensure ongoing compliance. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection on January 23, 2020, the facility failed to ensure exits from rooms were unobstructed. The outside stairs leading up to the rooms by building section AA and outside stairs outside of room 8 were both chained off and covered in snow and ice. In both sets of stairs, chaining the stairs off and not clearing them of ice/snow blocked a second exit from the rooms on the second floor of those buildings.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance Supervisor will be responsible to ensure all walkways and stairs are clean and salted from ice and snow in a timely manner to ensure no obstruction or blocked exits. Training with Supervisor was conducted during the state inspection which was held 1/21/20-1/24/20. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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.
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Observations
A review of December 2018 through December 2019 fire drill logs was conducted during the onsite inspection on January 21-24, 2020. The facility failed to document the number of patients/clients in the facility at the time of the fire drill conducted on March 28, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Quality Assurance Coordinator will write and review all fire drills to ensure all information is written down and correct. Training was conducted on 2/10/20. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a policy and procedures review on January 21-24, 2020, the facility failed to have the project director annually sign the policy and procedures manual. The last project director signature was on December 1, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance Coordinator will meet with project director on 3/2/20 to go over the Policy and Procedure binder, Project director looked over and signed off for 2020. Going forward the Quality Assurance Coordinator will meet with the Project Director on an annual basis to go over and update if necessary, the Policy and Procedure binder. The Project Director will then sign off on the binder annually in the month of January |
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 on January 21-24, 2020, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records # 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 25, 26, 27 and 28. The releases of information, all to the funding source, permitted release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress notes, laboratory reports, immunization records, medication records, and treatment/individualized service plan.
Client #1 was admitted on July 2, 2019 and was still active at the time of the inspection. The release of information form was dated July 2, 2019.
Client #2 was admitted on October 18, 2019 and was still active at the time of the inspection. The release of information form was dated October 18, 2019. In addition, a release of information form to a government agency, dated October 21, 2019, permitted release of the discharge summary.
Client #3 was admitted on June 26, 2019 and was still active at the time of the inspection. The release of information form was dated June 26, 2019.
Client #5 was admitted on April 4, 2019 and discharged on July 26, 2019. The release of information form was dated April 4, 2019.
Client #7 was admitted on July 24, 2019 and discharged on January 13, 2020. The release of information form was dated July 24, 2019.
Client #8 was admitted on December 7, 2019 and was still active at the time of the inspection. The release of information form was dated December 7, 2019.
Client #9 was admitted on November 25, 2019 and was still active at the time of the inspection. The release of information form was dated November 25, 2019.
Client #10 was admitted on October 29, 2019 and was still active at the time of the inspection. The release of information form was dated October 29, 2019.
Client #11 was admitted on November 15, 2019 and discharged on December 12, 2019. The release of information form was dated November 15, 2019.
Client #12 was admitted on July 22, 2019 and was discharged on November 5, 2019. The release of information form was dated July 22, 2019.
Client #13 was admitted on October 29, 2019 and discharged on December 2, 2019. The release of information form was dated October 19, 2019.
Client #14 was admitted on November 14, 2019 and discharged on January 13, 2020. The release of information form was dated November 14, 2019. In addition, a release of information form, dated November 14, 2019, to a government agency, permitted release of medication records.
Client #15 was admitted on December 20, 2019 and was still active at the time of the inspection. The release of information form was dated December 20, 2019.
Client #16 was admitted on January 4, 2020 and was still active at the time of the inspection. The release of information form was dated January 4, 2020. In addition, two release of information forms, both dated January 9, 2020 to government agencies permitted release of discharge summaries.
Client #17 was admitted on January 2, 2020 and was still active at the time of the inspection. The release of information form was dated January 2, 2020. In addition, a release of information form, dated January 9, 2020, to a government agency permitted release of a discharge summary.
Client #18 was admitted on October 21, 2019 and discharged on November 18, 2019. The release of information form was dated October 21, 2019. In addition, a release of information form, dated October 28, 2019 to a government agency permitted release of a discharge summary.
Client #19 was admitted on November 15, 2019 and discharged on December 13, 2019. The release of information form was dated November 15, 2019.
Client #20 was admitted on October 14, 2019 and discharged on October 14, 2019. The release of information form was dated October 4, 2019. In addition, a second release of information form to a different funding source, dated, October 4, 2019, permitted release of psychiatric evaluation, history and physical, discharge summary, laboratory reports, immunization records, medication records, treatment/individualized service plan, discharge instructions, biopsychosocial/diagnostic, continuing care plan, and nursing assessment.
Client #21 was admitted on June 14, 2019 and discharged on July 12, 2019. The release of information form was dated June 14, 2019.
Client #22 was admitted on January 16, 2020 and was still active at the time of the inspection. The release of information form was dated January 16, 2020.
Client #23 was admitted on January 5, 2020 and was still active at the time of the inspection. The release of information form was dated January 5, 2020.
Client #25 was admitted on June 26, 2019 and was discharged on July 10, 2019. The release of information form was dated June 26, 2019.
Client #26 was admitted on November 14, 2019 and discharged on January 15, 2020. The release of information form was dated November 14, 2019.
Client #27 was admitted on June 15, 2019 and discharged on July 10, 2019. The release of information form was dated June 15, 2019.
Client #28 was admitted on July 18, 2019 and discharged on July 29, 2019. The release of information form was dated July 18, 2019.
In addition, client #4 was admitted on April 19, 2019 and discharged on July 19, 2019. A consent to release information form to the funding source, dated April 19, 2019, did not indicate what was permitted to be released.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 14, 2018 inspection.
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Plan of Correction
All releases were reviewed and changed within the EMR system with the correct title and what should be checked off, going forward their will be no confusion during the admission process due to this update. All changes went into effect on January 17, 2020. Training for consents was completed on January 20, 2020.
Going forward PMRC will be conducting a training every quarter to ensure all staff are educated on consents.
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records on January 21-24, 2020, the facility failed to document a completed consent to release information form in client records # 14 and 21.
Client #14 was admitted on November 14, 2019 and discharged on January 13, 2020. A consent to release information form, dated November 14, 2019 to a government agency stated the purpose was for notification of an emergency situation, which is defined as an unforeseen event or condition requiring prompt attention". The listed purpose is outside the limits permitted under 4 Pa. Code 255.5(b).
Client #21 was admitted on June 14, 2019 and discharged on July 12, 2019. A consent to release information form, dated June 25, 2019, to an employer had "other" checked for the purpose without specifying what "other" meant.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All releases were reviewed and changed within the EMR system with the correct title and what should be checked off, going forward there will be no confusion during the admission process due to this update. All changes went into effect on January 17, 2020. Training for consents was completed on January 20, 2020.
Going forward PMRC will be conducting a training every quarter to ensure all staff are educated on consents.
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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 the review of client records on January 21-24, 2020, the facility failed to document a completed consent to release information form in client # 22 record, as the form was missing an expiration date.
Client #22 was admitted into the detoxification level of care on January 16, 2020 and was still active at the time of the inspection. The release of information form, dated January 16, 2020, to the funding source did not include an expiration date.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All releases were reviewed and changed within the EMR system with the correct title and what should be checked off, going forward there will be no confusion during the admission process due to this update. All changes went into effect on January 17, 2020. Training for consents was completed on January 20, 2020.
Going forward PMRC will be conducting a training every quarter to ensure all staff are educated on consents. |
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 a review of seven partial hospitalization client records on January 21-24, 2020, the facility failed to provide individual counseling sessions at least twice weekly in client records # 9, 10, and 13.
Client #9 was admitted into the partial hospitalization program on December 31, 2019 and was still active at the time of the inspection. The week of January 12-18, 2020, the client received one individual session on January 16, 2020.
Client #10 was admitted into the partial hospitalization program on November 27, 2019 and discharged to a lower level of care on January 3, 2020. The week of December 1-7, 2019, the client received one individual session on December 5, 2019.
Client #13 was admitted into the partial hospitalization program on October 27, 2019 and discharged to a lower level of care on December 2, 2019. The week of November 3-9, 2019, the client received one individual session on November 6, 2019. The week of November 10-16, 2019, the client received one individual session on November 12, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Supervisor will conduct a documentation training on 2/20/20 specific to level of care requirements. The clinical Director will ensure all training's are completed. |
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 a review of client records on January 21-24, 2020, the facility failed to document treatment plan updates within the regulatory timeframe in client records # 1, 3 and 7.
Client #1 was admitted on July 2, 2019 and was still active at the time of the inspection. A treatment plan update was completed on October 18, 2019 and the next update was due no later than December 18, 2019; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on June 26, 2019 and was still active at the time of the inspection. A treatment plan update was completed on September 5, 2019 and the next update was due no later than November 5, 2019; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted into the outpatient services level of care on September 9, 2019 and was discharged on January 13, 2020. A treatment plan update was completed on October 17, 2019 and the next update was due no later than December 17, 2019; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Supervisor will conduct a documentation training on 2/20/20 specific to level of care requirements. The clinical Director will ensure all training's are completed. |
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 on January 21-24, 2020, the facility failed to provide documentation that the clients received counseling services according to their individual comprehensive treatment plan in client records # 1, 3, 4 and 6.
Client #1 was admitted on July 2, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated October 18, 2019, indicated group sessions twice a week and individual sessions weekly. The record of service and progress notes indicated that the client did not receive individual counseling sessions between November 13 - November 26 and December 18-30, 2019 and January 10-20, 2020.
Client #3 was admitted on June 26, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated, September 5, 2019, indicated group sessions twice a week and individual sessions weekly. The record of service and progress notes indicated that the client did not receive individual counseling sessions between August 29-September 12, 2019 and no sessions after January 1, 2020. In addition, the client only received one group session on November 26, December 3 and December 10, 2019 during the weeks of November 24-30, December 1-7 and December 8-14, 2019.
Client #4 was admitted on May 13, 2019 into outpatient services and discharged on July 19, 2019. A treatment plan, dated May 13, 2019, indicated group and individual sessions once a week. A treatment plan update, dated June 17, 2019, indicated individual sessions twice a week. The record of service and progress notes indicated that the client did not receive individual counseling sessions between June 5-July 2 and July 4-16, 2019.
Client #6 was admitted on May 27, 2019 into outpatient services and discharged on July 17, 2019. A treatment plan, dated May 27, 2019 indicated group three times per week and individual sessions weekly. The record of service and progress notes indicated that the client did not receive individual sessions between June 15-July 17, 2019 and group sessions between June 29-July 17, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Supervisor will conduct a documentation training on 2/20/20 specific to level of care requirements. The clinical Director will ensure all training's are completed. |