INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellness Recovery 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 staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in two of two staff records.
Staff #4 was hired as a counselor assistant on December 12, 2023 and promoted to a counselor on June 1, 2024. The TB/STD training was to be completed by December 12, 2024. This training was not completed until February 5, 2025.
Staff #5 was hired as a counselor on June 1, 2023 and transitioned to a counselor assistant on May 1, 2024. The TB/STD training was to be completed by June 1, 2024. This training was not completed until February 5, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- All staff members in need of training will schedule the mandatory courses through the DDAP TMS to complete within the required timeframe. Any person unable to register will receive training through Wellness Recovery's contracted DDAP-approved trainer. The Clinical Director will be responsible for the implementation and monitoring of this procedure. |
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 administrative information, the facility failed to follow their policy and procedure for notifying the emergency contact for clients who discharge against facility advice in the detoxification and inpatient level of care in three of three records.
Act 41 of 2021, 71 P.S. 613.1(8.1) states Inpatient drug and alcohol treatment facilities must attempt to notify the emergency contact at least once and develop policies and procedures to implement a notification protocol which includes documenting notification attempts.
Client #4 was admitted to the inpatient level of care on December 9, 2024 and was discharged against facility advice on December 29, 2024. There was no documentation of an attempt to contact the emergency contact.
Client #10 was admitted to the detoxification level of care on January 8, 2025 and was discharged against facility advice on January 10, 2025. There was no documentation of an attempt to contact the emergency contact.
Client #11 was admitted to the detoxification level of care on February 18, 2025 and was discharged against facility advice on February 20, 2025. There was no documentation of an attempt to contact the emergency contact.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The clinical director will amend the existing emergency contact policy to reflect deficits identified in inspection results and provide adequate staff training on the new procedure. Specifically, the new policy will require that an emergency contact be notified by the nurse within 24 hours of a patient's early departure from treatment and properly document results. If consent to communicate is revoked, either verbally or formally on the respective form, nurses will be required to include this information clearly in their nursing notes and on the facility's AMA form. The Project Director will be responsible for monitoring compliance on this procedural change. |