INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Home 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 two personnel records, the facility failed to ensure that two employees had a written individual training plan that was developed annually.
Employee # 1 was hired as the Project Director on November 4, 2024 and was current in that position at the time of the inspection. Employee # 1 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 February 18, 2025.
Employee # 2 was hired as a counselor on December 23, 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 January 31, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have updated our Policy and Procedure manual to include a policy that all new hires will have an initial training plan at the time of hire to be completed within 30 days and updated trainings with in the year.HR will be responsible for enforcing this policy. |
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 July 2024 through February 2025 fire drill logs, the facility failed to document the amount of time to evacuate during each drill conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
the fire drill assessment document has been altered and updated to include a start and end time for the fire drill. Lead staff during the fire drill will ensure all times are recorded properly and the Executive Director will monitor. All staff will be trained on proper documentation of fire safety by end of business day 3/5/2025. |
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 eight applicable client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five records reviewed.
Client # 1 was admitted to the partial hospitalization level of care on October 7, 2024 and was transferred to a lower level of care on November 7, 2024. The record did not contain a client signed consent to release information form to the funding source; however, there was evidence of billing.
Client # 2 was admitted to the partial hospitalization level of care on October 9, 2024 and was discharged on November 8, 2024. The record did not contain a client signed consent to release information form to the funding source; however, there was evidence of billing.
Client # 3 was admitted to the partial hospitalization level of care on August 29, 2024 and was transferred to a lower level of care on September 24, 2024. The record did not contain a client signed consent to release information form to the funding source; however, there was evidence of billing.
Client # 6 was admitted to the partial hospitalization level of care on January 27, 2025 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, there was evidence of billing.
Client # 8 was admitted to the outpatient level of care on July 12, 2024 and was discharged on October 15, 2024. There was evidence of disclosures to a family member during a family counseling session on September 26, 2024; however, the record did not contain a client signed consent to release information form allowing the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There has since been a new billing company hired, and all patients now have an ROI form signed for the benefits and billing. All new clients will sign Assignment of Benefits / Release of Medical Information with the therapist upon admission. Executive Director will maintain compliance. |
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 thirteen client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 9 was admitted to the outpatient level of care on October 31, 2024 and was involuntarily discharged on January 22, 2025. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Policy and Procedure manual has been updated with a clear procedure for "Administrative Discharge" steps which include a new form to be signed by patient and therapist at time of discharge and monitored by the Executive Director. Unless there are safety concerns there is also a section for patient to appeal. And steps to have patient receive the documents. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation in two of six applicable records reviewed. The facility policy states that new admissions are to have a psychosocial evaluation completed within three days of admission.
Client # 2 was admitted on October 9, 2024 and was discharged on November 8, 2024. The psychosocial evaluation was not completed until November 8, 2024.
Client # 5 was admitted on February 12, 2025 and was active at the time of the inspection. The record contained a psychosocial assessment; however, it was not signed and dated to confirm it was completed according to the timeframe of the facility policy.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
following DDAP regulations a biopsychosocial will be completed within 3days. The Executive director will monitor and ensure all Biopsychosocial forms are completed within the timeframe given by doing chart checks on all charts within 3 days of admission. |
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 client records, the facility failed to provide individual counseling sessions two times weekly for clients in the partial hospitalization level of care in three of four applicable client records reviewed.
Client # 1 was admitted on October 7, 2024 and was transferred to a lower level of care on November 7, 2024. The record did not contain documentation of any individual sessions for the week of October 7, 2024, and only one individual session the weeks of October 14, 2024, October 21, 2024, and October 28, 2024.
Client # 2 was admitted on October 9, 2024 and was discharged on November 8, 2024. The record contained documentation of only one individual counseling session for the weeks of October 14, 2024, October 21, 2024, and October 28, 2024.
Client # 6 was admitted on January 27, 2025 and was active at the time of the inspection. The record did not contain documentation of any individual sessions for the weeks of January 27, 2025, February 3, 2025, and February 10, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
moving forward we will follow the DDAP requirements by ensuring all required documentation is completed and aligned with the level of care designated. The Executive Director will monitor for compliance by doing frequent chart checks |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed before the end of shift, per policy, in three of six records reviewed.
Client # 1 was admitted on October 7, 2024 and was transferred to a lower level of care on November 7, 2024. The record contained progress notes for group sessions occurring on October 9, 2024 and October 10, 2024, that were not completed until October 15, 2024. Additionally, the record contained a progress note for a group sessions occurring on October 22, 2024 and October 31, 2024, that were not completed until October 28, 2024 and November 8, 2024, respectively.
Client # 2 was admitted on October 9, 2024 and was discharged on November 8, 2024. The record contained progress notes for group sessions occurring on October 21, 2024, October 22, 2024, and October 23, 2024, that were not completed until October 28, 2024. Additionally, the record contained a progress note for a group session occurring on October 31, 2024, that was not completed until November 8, 2024.
Client # 3 was admitted on August 29, 2024 and was transferred to a lower level of care on September 24, 2024. The record contained a progress note for a group session occurring on August 29, 2024, that was not completed until October 1, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility Policy and Procedure manual has been updated with the following policies that all clinical documentation must completed and entered by end of work week and monitored by the Executive Director for accuracy. |
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 four of five applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed quarterly.
Client # 7 was admitted on September 23, 2024 and was discharged on February 18, 2025. The record did not contain case consultation notes.
Client # 8 was admitted on July 12, 2024 and was discharged on October 15, 2024. The record did not contain case consultation notes.
Client # 10 was transferred from a higher level of care on September 24, 2024 and was discharged on January 23, 2025. The record did not contain case consultation notes.
Client # 13 was transferred from a higher level of care on November 7, 2024 and was active at the time of the inspection. The record did not contain case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
case consultation regarding client's engagement in treatment to be completed at minimum once quarterly in first year and one time annually after the first year engaged in treatment by the clinical team and monitored by the Executive Director through chart audits done monthly. Executive Director monitoring and auditing charts is a new standard that has been added to ensure 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, 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, in one of two applicable records reviewed.
Client # 8 was admitted on July 12, 2024 and was discharged on October 15, 2024. The record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
all patients will have a discharge summary within 48 hours of discharge going forward.
The executive director will monitor and ensure compliance all staff will be trained by EOB 3/5/2025 |