INITIAL COMMENTS
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This report is a result of an on-site complaint and incident investigation conducted on December 28, 2015 - December 29, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site investigation, 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 investigation:
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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 and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of four personnel records reviewed.
The findings include:
Five personnel records which required documentation of mandatory communicable disease training were reviewed on December 28, 2015. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee #1.
Employee #1 was hired on 7/23/2013 as a security guard/shift supervisor. This employee was required to obtain six hours of HIV/AIDS and 4 hours of TB/STD training by 7/23/2015. Employee #1 failed to obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Employee #1 received his HIV/AIDS training on 10/15/15 and STD/TB training on 9/24/15. Both have been verified via signed attendance sheet and certificate of training now in his employee chart. These two training were outside the allotted time-frame stated in the standard. To avoid this occurring again and starting immediately, Human Resource Manager has identified a computer software program to be utilized for all employees that will alert HR manager to specific training needs and hours for all employees. This will ensure that all mandatory trainings such as STD/TB and HIV training hours and yearly training hours will be met. Training alerts will be prompted to the Human Resource Manager every 3 months to ensure all staff training hours are completed within the regulatory time-frame.
Human Resource Manager will review alerts (training needs) with the Clinical Director and Executive Director to schedule trainings in a timely manner.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 frequency of treatment services on the individual treatment and rehabilitation plan in three of three client records reviewed.
The findings include:
Three client records requiring documentation of the frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on 12/28/2015 - 12/29/2015. The individual treatment and rehabilitation plans contained in client records # 1, 2 and 3 did not include the specific frequency of treatment services.
Client # 1 was admitted to treatment on 9/23/2015 and discharged on 10/30/2015. The client's individual treatment and rehabilitation plan dated 9/25/2015 did not specify the frequency of individual and group counseling therapy.
Client # 2 was admitted to treatment on 9/13/2015 and discharged on 10/6/2015. The client's individual treatment and rehabilitation plan dated 9/16/2015 did not specify the frequency of individual and group counseling therapy.
Client # 3 was admitted to treatment on 9/13/2015 and still an active client at the time of the investigation. The client's individual treatment and rehabilitation plan dated 10/9/2015 did not specify the frequency of individual and group counseling therapy.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Quality assurance manager will review all 125 treatment plan templates and edit methods to reflect a more specific frequency of treatment services provided by Pocono mountain recovery center.
All treatment plan templates will be reviewed and implemented by 2/5/2016. Treatment Plans will be monitored weekly by the quality assurance manager to ensure methods and frequencies of treatment are correct and within regulator standards. These reports will be sent out weekly to all therapy staff along with Clinical Director and Executive Director to be reviewed.
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