INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4-5, 2015 by staff from the Division of Drug and Alcohol 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, it was determined that the facility failed to insure that the staff person appointed to the Project/Facility director position met the appropriate educational requirements.
The findings include:
A review of the personnel records was performed on November 4, 2015. The personnel record for Employee #1 indicated that the documentation for educational requirements for the position of Project/Facility director position were insufficient. The documentation indicated there Employee #1 has a Bachelor of Arts degree in Communication Studies and a Master of Science Degree in Instructional Technology.
Employee #1 was hired as Director of Compliance on 9/15/14 and was promoted to Project/Facility Director on June 29, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the event that the exception for the present Facility Director submitted to Gary Stauffer on November 18, 2015 is not granted, a new Project/Facility Director will be hired within 45 days. The CEO will be responsible for finding and interviewing potential replacement candidates for Project/Facility Director.
To ensure that this problem does not reoccur, prior to hiring a new Facility Director, the HR Coordinator will review and confirm the candidate?s qualifications to verify the candidate meets DDAP?s requirements for the position.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on November 5, 2015 at approximately 9:45 am.
Two dumpsters were observed on the grounds of the facility in a fenced in area. One dumpster was overflowing with cardboard/trash and the lid was not able to close. Additionally, the second dumpster ' s lid also wasn't closed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective November 6, 2015, the Director of Maintenance has begun to monitor the dumpsters daily to ensure that all trash is being disposed of properly into noncombustible, covered containers. The garbage will be removed at least once per week. On the days the garbage is not picked up, the Director of Maintenance will be responsible for ensuring that garbage is being disposed of appropriately including breaking down large items to allow containers to properly close.
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