INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2024 through January 4, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania 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(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.
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Observations
Based on a review of personnel records, the facility failed to ensure the completion of a written individual training plan for each employee, which is to be developed with input from both the employee and the supervisor, in two of eight personnel records reviewed.
Employee #7 was hired as a counselor on August 28, 2023. There was no documentation of an individual training plan in the personnel record at the time of the inspection.
Employee #8 was hired as a counselor assistant on September 8, 2023. There was no documentation of an individual training plan in the personnel 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
Chief Clinical Officer (CCO) was informed that all staff must have training plans completed for the next year (2024) at the time of the annual inspection for 2023. CCO ensured the completion of all 2024 training plans, including Employees #7 & #8 already. CCO will include all staff 2024 training plans in the weekly DDAP Compliance Meetings to ensure presence and accuracy of training to fulfill this regulation. |
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 facility's decision to involuntarily terminate the client's treatment in one of one applicable client records reviewed.
Client #4 was admitted into the partial hospitalization activity on September 8, 2023 and was administratively discharged on October 4, 2023. There was no documentation of written notice of the involuntary termination in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer (CCO) has ensured that Client #4 was sent a letter after receiving this citation. Furthermore, the CCO will include this regulation in the weekly DDAP Compliance Meetings to ensure that all clients that are administratively discharged received a typed letter outlining the reason(s) they were administratively discharged and the policy for the individual to request, in writing, an administrative review for possible re-admission. |
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, the facility failed to provide the client an opportunity to request reconsideration of a decision terminating treatment in one of one applicable records reviewed.
Client #4 was admitted into the partial hospitalization activity on September 8, 2023 and was administratively discharged on October 4, 2023. There was no documentation in the record of the facility providing the client an opportunity to request reconsideration of termination at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer (CCO) has ensured that Client #4 was sent a letter after receiving this citation. Furthermore, the CCO will include this regulation in the weekly DDAP Compliance Meetings to ensure that all clients that are administratively discharged received a typed letter outlining the reason(s) they were administratively discharged and the policy for the individual to request, in writing, an administrative review for possible re-admission. All letters will be uploaded in the individual client's chart with date the letter was sent. |
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 a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days for clients admitted into the partial hospitalization activity in two of two applicable client records reviewed.
Client #2 was admitted on November 22, 2023 and was active at the time of inspection. The comprehensive treatment and rehabilitation plan was completed on November 27, 2023 and the first update was due no later than December 27, 2023; however, the update was not completed at the time of inspection.
Client #7 was admitted on October 4, 2023 and was discharged on November 16, 2023. The comprehensive treatment and rehabilitation plan was completed on October 12, 2023 and the first update was due no later than November 12, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer (CCO) can ensure that clients #2 & #7 have updated comprehensive treatment and rehabilitation plans (rectified on 1/10/24) to reflect the appropriate timeframes. Furthermore, the CCO will include accurate timeframe audits for all clients' compressive treatment and rehabilitative plans in weekly DDAP Compliance Meetings. These audits will check for DDAP regulations and Policy & Procedure for this aspect of the Electronic Medical Record. |