INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Britelife Recovery at Hanover 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 #5, who was hired as a counselor on November 28, 2022, did not meet the education and experience requirements to be a counselor. At the time of the hire, the employee had a high school diploma and no experience.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
704.7(b) LICENSURE
Counselor Qualifications
Plan of correction:
Hiring Procedure-
A change, effective 2/13/2023, has been enacted in hiring/ onboarding process company wide. BriteLife Recovery's previous procedure for completion of onboarding paperwork was submission of a diploma or transcript along with a respective resume. Corporate has changed the onboarding process to require copies of both a diploma and a certified transcript. This change of process will allow BriteLife Recovery to confirm that staff meets the requirements for DDAP regulations. The onsite Clinical Director and Executive Director will first assess the qualifications of the individual to meet DDAP requirements. Once the applicant is put through to the hiring process, the Corporate HR staff will also verify the qualifications before an offer is made.
Immediate Actions:
Employee #5 has been reassigned to a Counselor Assistant, effective 2/13/2023. Over the next 90 days, employee will be under direct observation of a trained counselor and/or clinical supervisor. Employee #5 will continue to work on obtaining an Associate's Degree or a certification as an Addictions Counselor through the PA Certification Board. If this is not able to be obtained before 5/14/2023, she will be reassigned to a behavioral health technician position.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to keep each bathroom in a clean and sanitary manner at all times. The men's common bathroom #1 had a bar of soap and two shampoo bottles on the floor of the shower.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.6 (7) LICENSURE
Bathrooms
Each client has received a plastic caddy in the interim, effective 2/20/2023.
Liquid soap dispensers have been ordered for all showers and will be installed upon delivery. This will be installed by 3/6/23.
The Director of Operations will oversee this process.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of fire drills from May 2022 through December 2022, the facility failed to conduct fire drills during sleeping hours at least every six months. The only sleeping drill during this time frame was conducted on December 27, 2022.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.10 (d) (5) LICENSURE
Fire safety
To ensure compliance with the standard, after hour fire drills have been scheduled for 2nd week in May and November 2023. The date and time will be selected by the Executive Director and submitted to Director of Operation who will conduct the drill. This change was effective 2/10/2023.
The drills will be recorded and available for review by the Director of Operations.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they have been notified of their rights. The signed client rights did not inform the clients that reasons for removing sections shall be documented in the record in fourteen out of fourteen records reviewed.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.30 (3) LICENSURE
Client rights
The Client Rights document previously stated "The Clinical Director may remove certain parts of the file given sound clinical rationale." On February 8, 2023, during the audit, Clinical Director updated the Client Rights document to state "The Clinical Director may remove certain parts of the file given sound clinical rationale. This rationale will be documented and shared with the client." Clinical Director also had all current clients sign new Client Rights on February 8, 2023 during the audit. Clinical Director has also updated the Client Rights to reflect this change in the Client Handbook.
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