INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13-14, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Promont 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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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 personnel files, the facility failed to instruct staff in the use of a fire extinguisher upon employment in two out of three files reviewed. The facility opened on January 9, 2023.
Employee #1 was hired on July 1, 2022 and was still in employment at the time of the inspection. The training was completed on March 29, 2023.
Employee #3 was hired on January 1, 2023 and was still in employment at the time of the inspection. The training was completed on March 28, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be trained in how to use fire extinguishers within 7 days of hire.
Training will be documented in personnel file, clinical director will monitor, as individuals are hired and through quarterly audits. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of fire drill logs from January through August 2023, the facility failed to conduct unannounced fire drills at least once a month. During this time period, the only fire drill conducted was in May 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Unannounced fire drills will be completed on a monthly basis moving forward. The drills will be conducted on different days of the week, time of day, different shifts, etc. This will be documented and critiqued on Fire Drill Form kept by CD. |
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 personnel files, the facility failed to train staff on assigned tasked during emergencies upon employment in two out of three files reviewed. The facility opened on January 9, 2023.
Employee #1 was hired on July 1, 2022 and was still in employment at the time of the inspection. The training was completed on March 29, 2023.
Employee #2 was hired on January 1, 2023 and was still in employment at the time of the inspection. The training was completed on March 28, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be trained in assigned tasks during emergencies, within 7 days of hire. This will be documented in personnel files.
Clinical Director will monitor as individuals are hired and will continue on ongoing basis through quarterly audits. |
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 the review of fire drills logs, the facility failed to document the exit route used, and whether the fire alarm or smoke detector was operative at the time of the drill.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire Drill forms/procedures have been updated to record which exit route was used to evacuate the facility as well as whether or not the fire alarm and smoke detectors are operational during the drill. This will be completed and critiqued on a monthly basis. |
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 outpatient client records, the facility failed to align the specific information to be disclosed with the purpose in two out of eleven records reviewed. The consent forms permitted "any and all information" to be released.
Client #6 was admitted on March 21, 2023 and discharged on April 28, 2023. A consent form was dated March 20, 2023 to an insurance company.
Client #10 was admitted on March 14, 2023 and was still active at the time of the inspection. Two consent forms dated April 13, 2023 were to a laboratory and an insurance company.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Per regulation 709.28 all consents will align with the person/organization the consent is for. "Any and all information" will only be utilized for appropriate parties, not insurance companies, LabCorp, etc. Only specific information will be disclosed based on who the consent is for.
Clinical director will monitor consents, this will be part of quarterly chart audits completed by CD. |
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 outpatient client records, the facility failed to document a date, event or condition upon which the consent will expire in three out of eleven records reviewed.
Client #3 was admitted on April 6, 2023 and discharged on July 7, 2023. The consent was dated April 6, 2023 to an emergency contact.
Client #10 was admitted on April 14, 2023 and was still active at the time of the inspection. The consent form was dated April 13, 2023 to a physician.
Client #11 was admitted on July 21, 2023 and was still active at the time of the inspection. The consent form was dated July 21, 2023 to a family member.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All consent forms will have a pre-set date or a specific date, based on client preference, in which the consent expires.
Clinical director will monitor that releases are completed, including the aforementioned information. Chart audits will be done on a quarterly basis. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of outpatient client records, the facility failed to document whether a copy of a consent to release information form was offered to the client in ten out of eleven records reviewed.
Client #1 was admitted on May 8, 2023 and was still active at the time of the inspection. The consent forms were dated May 3, 2023 to a laboratory and emergency contact.
Client #2 was admitted on June 26, 2023 and was still active at the time of the inspection. The three consent forms were dated June 22, 2023 to a laboratory, physician and emergency contact.
Client #3 was admitted on April 6, 2023 and was discharged on July 7, 2023. The consent form was dated April 6, 2023 to an emergency contact.
Client #4 was admitted on July 10, 2023 and discharged on September 11, 2023. Three consent forms were dated June 27, 2023 to a physician, laboratory and emergency contact. An additional consent form was dated August 21, 2023 to another treatment facility.
Client #5 was admitted on August 11, 2023 and discharged on September 11, 2023. Four consent forms were dated August 7, 2023 to two family members, another treatment facility and an emergency contact. On August 9, 2023, a consent form was to a family member. In addition, a consent form dated August 10, 2023 was to another treatment facility.
Client #6 was admitted on March 21, 2023 and discharged on April 18, 2023. Four consent forms dated March 20, 2023 were to a hospital, employee assistance program, physician and pharmacy.
Client #7 was admitted on July 24, 2023 and discharged on September 11, 2023. A consent form dated July 24, 2023 was to probation.
Client #8 was admitted on August 1, 2023 and discharged on September 5, 2023. Three consent forms dated August 1, 2023 were to a physician, laboratory and emergency contact.
Client #10 was admitted on April 14, 2023 and was still active at the time of the inspection. Three consent forms dated April 13, 2023 were to a physician, laboratory and an insurance company.
Client #11 was admitted on July 21, 2023 and was still active at the time of the inspection. Four consent forms dated July 21, 2023 were to a family member, physician, laboratory and emergency contact.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All consent forms now have the option for client to "accept or decline" a copy of the consent. The appropriate button will be checked based on client preference. Staff was trained to ensure this is completed accurately.
Clinical director will monitor for ongoing compliance. This will be done as intake evaluations are completed, CD has to sign off, also monitored at quarterly chart audits. |