INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gemini Recovery Centers at Scranton 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to provide documentation showing that clinical supervisors had monthly meetings with their supervisors for the first six months of employment in that position, in one record reviewed.
Employee # 2 was hired as the Clinical Supervisor on April 15, 2024 and has remained in that position. There was no documentation of monthly supervision in the personnel record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has begun supervision of Employee #2. The monthly meetings and supporting documentation will occur for 6 months and will be filed in the employee personnel record.
The Executive Director has created a personnel checklist for employees and will ensure each newly hired employee has the appropriate training and documentation placed in their personnel file upon hire.
The Executive Director will ensure implementation of the above corrective action to remain in compliance.
The corrective action will take place immediately. |
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 two personnel records, the facility failed to ensure that two employees had a written individual training plan that was developed annually.
Employee # 1 has been in the position of Project and Facility Director since November 17, 2023. Employee # 1 should have had an initial individual training plan developed within 30 days of the date of hire; however, the record did not contain a written individual training plan.
Employee # 2 was hired as the Clinical Supervisor on April 15, 2024 and was current in that position at the time of the inspection. Employee # 2 should have had an initial individual training plan developed within 30 days of the date of hire; however, a written individual training plan was not developed until May 24, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has a developed an individual training plan that is documented for Employee #1 and placed in the personnel file.
Employee #2 has a training plan that will be reviewed periodically to ensure the goals and plans are current. Additionally, upon one year of employment, a new plan will be developed and monitored by the Executive Director.
The Executive Director will ensure training plans and supporting documentation will occur within 30 from the date of hire on any employee to remain in compliance.
The corrective plan of action will take place immediately. |
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 two personnel records, the facility failed to demonstrate that a sufficient number of staff persons had first aid training, as only one of the two full-time staff members was trained in first aid between April 15, 2024 and July 29, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has enrolled employees in first aid training.
The Executive Director has developed a checklist for new employees and will ensure each employee has the appropriate training and supporting documentation placed in their personnel file.
The corrective plan of action will begin 8/20/2024 once the training has been completed. |
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 a review of two personnel records, the facility failed to ensure that each applicable staff member was instructed in the use of fire extinguishers upon employment.
Employee # 1 was hired as the Project and Facility Director on November 17, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, the record did not contain documentation that the employee was trained in the use of fire extinguishers.
Employee # 2 was hired as the Clinical Supervisor on April 15, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, the record did not contain documentation that the employee was trained in the use of fire extinguishers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has scheduled a fire extinguisher training for all employees.
The Executive Director has developed an employee checklist for staff orientation and will ensure each newly hired employee has the appropriate trainings and supporting documentation in their personnel files.
The corrective plan of action will take place on 08/21/2024 once the training is completed. |
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 a review of two personnel records, the facility failed to ensure that each applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 1 was hired as the Project and Facility Director on November 17, 2023 and is current in that position. Employee # 1 began working shifts on November 17, 2023; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.
Employee # 2 was hired as the Clinical Supervisor on April 15, 2024 and is current in that position. Employee # 2 began working shifts on April 15, 2024; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has scheduled all employees for emergency response training.
The Executive Director has developed an employee checklist that ensures all employees receive the appropriate training and documentation upon hire for staff orientation and will be responsible for monitoring for continued compliance.
The corrective action plan will take place on 08/21/2024 when the training is complete. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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
Based on a review of the December 2023 through June 2024 fire drill logs, the facility failed to document the time of the drill, exit route used, problems encountered, and whether the fire alarm or smoke detector was operative during each drill conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has amended the fire drill log and added new rows to that include the time the drill took place, exit route used, problems encountered, and whether the fire alarm or smoke detector was operative during each drill conducted.
The Executive Director will monitor each log and ensure documentation is accurate and completed in its entirety.
The corrective action plan will take place immediately. |
709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the Project ' s policies and a discussion with staff, the facility failed to ensure that the written procedures for the management of treatment/rehabilitation services included specific timeframes for when intake documentation, such as the completion of consent to treatment forms, disclosure to the client of criteria for admission, treatment, completion, and discharge, and client orientation to the project, were to be completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the policy referenced in observation 0157.
The Executive Director has amended the policy and procedure for the management of treatment/rehabilitation services that include time frames for when intake documentation, completion of consent to treatment forms, disclosure to the client of criteria for admission, treatment, completion, and discharge, and client orientation to the project, were to be completed.
The Executive Director disseminated the amended policy to staff followed by a review of the policy and time frames.
The Clinical Director will be responsible for ensuring the policy and procedure are being followed by conducting on-going chart reviews.
The corrective action date will be 08/28/2024. |
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 eight client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in four of four applicable records reviewed.
Client # 2 was admitted to the Partial Hospitalization level of care on December 6, 2023 and was discharged on January 8, 2024. The record contained a consent to release information form to the funding source signed by the client on December 6, 2023, that was missing the specific information to be disclosed.
Client # 4 was admitted to the Outpatient level of care on February 6, 2024 and was discharged on February 26, 2024. The record contained a consent to release information form to the funding source signed by the client on February 6, 2024, that was missing the specific information to be disclosed.
Client # 5 was admitted to the Outpatient level of care on January 16, 2024 and was discharged on February 9, 2024. The record contained a consent to release information form to the funding source signed by the client on January 17, 2024, that was missing the specific information to be disclosed.
Client # 6 was admitted to the Outpatient level of care on March 1, 2024 and was discharged on March 11, 2024. The record contained a consent to release information form to the funding source signed by the client on March 1, 2024, that was missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the records of the discharged clients in this observation.
The Executive Director has scheduled a training with clinical staff on properly filling out consent/release forms. The Executive Director will be responsible for ensuring the corrective action is implemented and the Clinical Director will be responsible for continued monitoring of client records to ensure continued compliance.
The corrective action will be completed by 08/26/2024.
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709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in one of one applicable record reviewed. The facility policy manual indicates that case consultation notes will be completed upon admission.
Client # 2 was admitted on December 6, 2023 and was discharged on January 8, 2024. The case consultation note was not completed until January 9, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the discharged client records in this observation.
The Executive Director will amend the policy and procedure to reflect a case consult note be completed during treatment and as necessary and not upon admission.
The Executive Director will ensure the corrective action is implemented and will disseminate the amended policy to clinical staff on 08/26/2024.
The Clinical Director will be responsible for on-going monitoring of client records to ensure continued compliance. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary within seven days of discharge, in one of two applicable records reviewed.
Client # 2 was admitted on December 6, 2023 and was discharged on January 8, 2024. The record did not contain documentation of a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the discharged client record in observation 1613.
The Executive Director has scheduled a training with clinical staff on the policy and procedure for client's that are discharged.
The Clinical Director will be responsible for on-going monitoring of client records post-discharge to ensure continued compliance.
The corrective action plan will be completed by 08/26/2024.
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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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in one of two applicable records reviewed.
Client # 3 was admitted on May 20, 2024 and was discharged on June 4, 2024. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the discharged client record in observation 1615.
The Executive Director has scheduled a training for clinical staff regarding follow-up information once a client is discharged; including supporting documentation to be entered in the client record by staff.
The Clinical Director will be responsible for on-going monitoring of the client records to ensure continued compliance.
The corrective action plan will take place by 08/26/2024. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in one of three applicable records reviewed.
Client # 4 was admitted on February 6, 2024 and was discharged on February 26, 2024. The individual treatment and rehabilitation plan was completed on February 7, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the discharged client record in observation 1879.
The Executive Director has amended the template for the individual treatment plan, in the electronic medical record system to reflect type and frequency of treatment each client will receive.
The Clinical Director will be responsible for on-going monitoring of each client record to ensure compliance.
The corrective action plan has already been completed. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in two of three applicable client records reviewed.
Client # 4 was admitted on February 6, 2024 and was discharged on February 26, 2024. The individual treatment and rehabilitation plan was completed on February 7, 2024; however, the plan did not include documentation of the proposed type of support services.
Client # 5 was admitted on January 16, 2024 and was discharged on February 9, 2024. The individual treatment and rehabilitation plan was completed on January 22, 2024; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has scheduled a training with clinical staff on types of support services.
The Clinical Director will be responsible for ensuring the appropriate documentation and information is included in a clients individual treatment plan and proposed type of support services are identified. The Clinical Director will be responsible for on-going monitoring of client records.
The corrective action will take place by 08/26/2024. |
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 a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in one of one applicable record reviewed. The facility policy manual indicates that case consultation notes will be completed upon admission.
Client # 8 was admitted on July 8, 2024 and was active at the time of the inspection. The record did not contain documentation of a case consultation note upon admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the discharged client record in observation 1905.
The Executive Director will amend the policy and procedure to reflect a case consult note be completed during treatment and as necessary and not upon admission.
The Executive Director will ensure the corrective action is implemented and will disseminate the amended policy to clinical staff on 08/26/2024.
The Clinical Director will be responsible for on-going monitoring of client records to ensure continued compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary within seven days of discharge, in two of four applicable records reviewed.
Client # 4 was admitted on February 6, 2024 and was discharged on February 26, 2024. The discharge summary was not completed until May 24, 2024.
Client # 6 was admitted on March 1, 2024 and was discharged on March 11, 2024. The record did not contain documentation of a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the discharged client recordsa in this observation.
The Executive Director has scheduled a training with clinical staff on the policy and procedure for client's that are discharged.
The Clinical Director will be responsible for on-going monitoring of client records, including supporting documentation being entered in client records in a timely manner to ensure continued compliance.
The corrective action plan will be completed by 08/26/2024. |
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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of four applicable records reviewed.
Client # 4 was admitted on February 6, 2024 and was discharged on February 26, 2024. The record did not contain documentation of follow-up information.
Client # 6 was admitted on March 1, 2024 and was discharged on March 11, 2024. The record did not contain documentation of follow-up information.
Client # 7 was admitted on May 16, 2024 and was discharged on May 29, 2024. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has reviewed the discharged client record in observation 1911.
The Executive Director has scheduled a training for clinical staff regarding follow-up information once a client is discharged; including supporting documentation to be entered in the client record by staff.
The Clinical Director will be responsible for on-going monitoring of the client records to ensure continued compliance.
The corrective action plan will take place by 08/26/2024. |