INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4-5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pocono Mountain Recovery Center, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, who was hired as a counselor on August 8, 2022, did not meet the experience requirements to be a counselor. At the time of hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
Employee #6, who was hired as a counselor on May 11, 2022, did not meet the experience requirements to be a counselor. At the time of hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #4 has been changed from a Counselor to a Counselor Assistant effective 03/01/2023. She will have direct observation with documentation from a trained counselor or clinical supervisor for three months, as of 03/01/2023. Upon completion of the direct observation, she will have close supervision with documentation from a trained counselor or clinical supervisor for nine months, as of 06/01/2023. The expected completion date will be 03/01/2024.
Employee #6 has one year of clinical experience at the time of the survey.
Going forward, the Clinical Director and/or Clinical Supervisor will ensure that the program adheres to the supervision requirements as stated in §704.9. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #10 was hired on February 4, 2020 and was promoted to the position of counselor assistant on June 13, 2022; and was still employed at the time of the inspection. She had no documentation of direct or close supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #10: She will have direct observation with documentation from a trained counselor or clinical supervisor for three months, as of 03/01/2023. Upon completion of the direct observation, she will have close supervision with documentation from a trained counselor or clinical supervisor for nine months, as of 06/01/2023. The expected completion date will be 03/01/2024.
Going forward, the Clinical Director and/or Clinical Supervisor will ensure that the program adheres to the supervision requirements as stated in §704.9. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in five out of eleven employee records reviewed.
Employee #4 was hired on August 8, 2022 as a counselor and was still in the position as of the date of the inspection. The plan is dated October 25, 2022.
Employee #6 was hired on May 11, 2022 as a counselor and was still in the position as of the date of the inspection. The plan is dated August 2, 2022.
Employee #7 was hired on January 3, 2022 as a counselor and was still in the position as of the date of the inspection. The plan is dated April 2, 2022.
Employee #8 was hired on January 3, 2022 as a counselor and was still in the position as of the date of the inspection. The plan is dated October 19, 2022.
Employee #9 was hired on May 17, 2022 as a counselor and was still in the position as of the date of the inspection. The plan is dated October 20, 2022.
Employe #10 was hired on June 13, 2022 as a counselor assistant and was still in the postion as of the date of the inspection. The plan was dated August 2, 2022
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility has implemented a policy that requires training plans for new employees to be completed with the first 30 days of employment, annual training plans to be completed by December 31st of each year in conjunction with annual performance evaluations, and all plans to be filed in the employee's facility personnel record. The Director of Clinical Services will be responsible for implementing and ensuring that these are completed in the appropriate time frames. The Director of Clinical Services and the Human Resources Manager will be responsible for monitoring this for compliance. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The screen in two windows of suite #20 were torn out and the windows were open.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The torn screens have been replaced.
As of 03/01/23, inspection of screens will be added to the Maintenance Department's monthly facility inspection. Screens will then be replaced as needed.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each patient's bathroom. Suite #20 did not have paper towels.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the December 1, 2021 licensing inspection.
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Plan of Correction
Approximately 40% of the rooms have a mechanical hand dryer. The Director of Facility Operations will ensure that the remaining mechanical hand dryers will be installed by 06/01/23. As of 02/03/23, Housekeeping will check all rooms a minimum of twice per day and resupply paper towels as needed for those rooms without mechanical hand dryers. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document that each staff shall have an annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
Employee #3 was hired as a clinical supervisor on December 18, 2017 and was still in the position as of the date of the inspection. There was no documentation of an evaluation completed in 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility has implemented a policy that requires performance evaluations to be done annually, by December 31st of each year, reviewed by the employee, signed by the employer and the supervisor, and filed in the employee's personnel record at the facility record. All department heads are responsible for the completion of the evaluations of their employees. The Human Resources Manager is responsible for tracking the completion of the evaluations throughout November and December of each year and will follow up with department heads on the timely completion of evaluations. |
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 the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in four out of twenty-two client records reviewed.
Client #13 was admitted on October 7, 2022 and was still active at the time of the inspection. A release of information form for a funding source dated October 12, 2022 did not have documentation that the client was offered a copy of the consent form.
Client #14 was admitted on September 27, 2022 and was still active at the time of the inspection. A release of information form for a funding source dated September 27, 2022 did not have documentation that the client was offered a copy of the consent form.
Client #15 was admitted on November 25, 2022 and was still active at the time of the inspection. A release of information form for a funding source dated November 25, 2022 did not have documentation that the client was offered a copy of the consent form.
Client #16 was admitted on November 18, 2022 and was still active at the time of the inspection. A release of information form for a funding source dated November 18, 2022 did not have documentation that the client was offered a copy of the consent form.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility's Risk Management Assistant has included a prompt in the electronic record to require that either "denied" or "approved" are checked for a patient being a copy of the consent. Monitoring will occur through supervisor oversight and through monthly record reviews.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered. Client #23 was prescribed Wixela to be given one time daily. There was no documentation of the medication being administered or the reason not administered on December 28, 2022 and January 1, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing will ensure that all nurses are educated by 02/28/23 on the correct procedure to document medication administration at the time of administering the medication. The Director of Nursing will ensure that all nurses are educated by 02/28/23 on the correct procedure to document a reason a medication is not administered when this occurs. The Director of Nursing and Nurse Managers will ensure that the Medication Administration Records of 20 discharges per month will be audited for a minimum of three months to ensure compliance with the correct procedure. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of facility records, the facility failed to inform the Department of unusual incidents within the required three days. It was discovered that the facility had unusual incidents occur on October 20, 2022; October, 31, 2022; November 23, 2022; December 22, 2022; and December 15, 2022, all of which involved presence of an ambulance. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A protocol has been implemented effective 02/02/2023 in which there is an on-site designated staff member at PMRC and an on-site designated staff member at HCRC to ensure that unusual incidents are submitted within three business days. The facility's Risk Management Assistant is responsible for implementation and for daily monitoring for compliance.
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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 partial hospitalization client records, the facility failed to provide a complete client record, which is to include a follow-up information in one out of three applicable records reviewed.
Client #17 was admitted on August 15, 2022 and was discharged on September 29, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Manager will ensure that all counselors are educated on the policy and procedure regarding aftercare follow-up and documentation. Monitoring will occur through supervisor oversight and through monthly record reviews. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of residential client records, the facility failed to document treatment plan updates within the guidelines established by the facility's policy and procedure manual in two out of six applicable records reviewed. The facility's policy and procedures manual states the treatment plan updates must be completed by day 14 and every 14 days thereafter.
Client #6 was admitted on July 18, 2022 and was discharged on August 15, 2022. A treatment plan update was completed on July 27, 2022 and the next update was due no later than August 10, 2022; however, none was competed.
Client #7 was admitted on June 15, 2022 and was discharged on July 13, 2022. A treatment plan update was completed on June 24, 2022 and the next update was due no later than July 8, 2022; however, it was competed on July 13, 2022.
These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Q&PI revised the policy to require a preliminary treatment plan within 24 hours of admission, a treatment plan within 72 hours of admission, a treatment plan review by day 14, and a final treatment plan disposition within 72 hours of discharge. The Clinical Director will ensure that all clinical staff are educated by 03/01/2023 on the policy, procedure, and documentation for treatment plans. Monitoring will occur through supervisor oversight and through monthly record reviews. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 residential client records, the facility failed to provide a complete client record, which is to include case consultations in three out of six applicable records reviewed.
Client #5 was admitted on December 2, 2022 and was discharged on December 27, 2022.
Client #6 was admitted on July 18, 2022 and was discharged on August 15, 2022.
Client #7 was admitted on June 15, 2022 and was discharged on July 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Q&PI revised the policy to require that a case consultation occurs by day 14. The Clinical Director will ensure that all clinical staff are educated by 03/01/2023 on the policy, procedure, and documentation for treatment plans. Monitoring will occur through supervisor oversight and through monthly record reviews. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 residential client records, the facility failed to provide a complete client record, which is to include a follow-up information in two out of three applicable records reviewed.
Client #5 was admitted on December 2, 2022 and was discharged on December 27, 2022.
Client #6 was admitted on July 18, 2022 and was discharged on August 15, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that all staff are educated by 03/01/23 on the policy and procedure regarding aftercare follow-up and documentation. Monitoring will occur through supervisor oversight and through monthly record reviews. |
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 outpatient client records, the facility failed to provide a complete client record, which is to include a follow-up information in four out of five applicable records reviewed.
Client #19 was admitted on October 29, 2022 and was discharged on November 12, 2022.
Client #20 was admitted on June 3, 2022 and was discharged on July 9, 2022.
Client #21 was admitted on September 2, 2022 and was discharged on October 8, 2022.
Client #22 was admitted on August 31, 2022 and was discharged on October 2, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 1, 2021 licensing inspection.
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Plan of Correction
The Clinical Services Manager will ensure that all staff are educated by 03/01/23 on the policy and procedure regarding aftercare follow-up and documentation. Monitoring will occur through supervisor oversight and through monthly record reviews. |