INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peace Valley 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 personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training within the regulatory timeframe in one of one applicable personnel records reviewed.
Employee # 7 was hired as a counselor on April 29, 2020 and was due to have received the HIV/AIDS training no later than April 29, 2021. There was no documentation that the HIV/AIDS training was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PVR had employee #7 complete the HIV/AIDS training on 7/1/2021. Facility director will ensure that all employees have their HIV/AIDS training completed within their first year of employment with PVR.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project/facilitty director completed at least 12 clock hours of training during the facility's January 1, 2020 through December 31, 2020 training year.
Employee #1 was hired as the project/facility director on August 15, 2019. The personnel record documented 0 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 will have all 12 clock training hours completed for the next training year. Facility Director and Clinical Director will check HR files bi-monthly to ensure that all employees are up to date on their trainings. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of training during the facility's January 1, 2020 through December 31, 2020 training year in one of one applicable personnel records reviewed.
Employee #2 was hired as a clinical supervisor on August 15, 2019. The personnel record documented 0 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 (clinical supervisor) completed her 12 clock hours of trainings for the current training year already, as of 7/1/2021. Facility Director will ensure that she completes 12 clock hours every training year. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PVR researched and found a public accountant that will be completing the annual financial audits moving forward. The CEO and CFO will have the financial audit for the year just surveyed by 7/16/2021. Facility Director will ensure that the CFO gets this completed yearly, as needed. |
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 client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in fourteen of fourteen client records reviewed.
Each client record reviewed contained release of information forms to the billing company and/or the funding source that allowed for the release of treatment plans, psychological assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations, discharge planning and discharge summary, all of which exceeded the limits established by 4 Pa. Code 255.5.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PVR created consents to the funding source for each client. Each consent is completed upon client's initial intake. Facility Director created the consents in the EHR on 06/17/2021. Facility Director and Clinical Director will ensure that the consents are being completed during regular chart checks. All active clients had new consents completed in their charts by 06/17/2021. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on release of information forms in fourteen of fourteen applicable client records reviewed. Each release of information form in every client record reviewed failed to document the dated signature of the witness.
This is a repeat citation from the November 23, 2020 licensing inspection.
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Plan of Correction
PVR created the witness signature information on all release of information forms in the EHR. Facility Director created the witness information in the EHR on 6/17/2021. Facility Director and Clinical Director will ensure that the consents are being completed during regular chart checks. All active clients had new consents completed in their charts by 06/17/2021. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 client's treatment and rehabilitation plan in all seven of seven applicable outpatient client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director educated clinicians on the client treatment plans on 6/17/2021. Facility Director and Clinical Director will ensure that the treatment plans are completed correctly during regular chart checks. All active clients had new treatment plan goals and objectives added to their current treatment plans on 6/17/2021. |
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 client's treatment and rehabilitation plan in all seven of seven applicable partial hospitaliztion client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director educated clinicians on the client treatment plans on 6/17/2021. Facility Director and Clinical Director will ensure that the treatment plans are completed correctly during regular chart checks. Clinicians added the frequency/types of groups and individual sessions to each active PHP client treatment plans on 6/17/2021. |