INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, - 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Oil Region Recovery 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 employee records, the facility failed to provide documentation of staff persons receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics two of two applicable records.
Employee # 4 was hired as a support staff person on July 23, 2018 and was promoted to counselor on July 16, 2019. Training was due to be completed by July 2020. As of the date of the inspection, there was no documentation the HIV/AIDS and the TB/STD training was completed.
Employee # 8 was hired as a support staff person on March 31, 2019. Training was due to be completed by March 2021. As of the date of the inspection, there was no documentation the HIV/AIDS and the TB/STD training was completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 4, 2020 inspection.
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Plan of Correction
Communicable disease training curriculum was downloaded from DDAP website. All staff out of compliance will be trained with that curriculum by the Clinical Director by 6/30/21 in HIV and TB/STD. Clinical Director will monitor staff training plans on a monthly basis to ensure staff are scheduled and trained for the appropriate trainings. |
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 employee records, the facility failed to provide documentation the Project Director had at least 12 clock hours of training annually.
Employee # 1 began as the director on May 1, 2018 and was still in this position at the time of the inspection. The facility July 1, 2019 through June 30, 2020 training year was reviewed. Employee #1 did not document the required 12 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director is scheduled for 18 hr training on 6/14-16/21. Project Director will continue to schedule at least 12 hours of training annually. This will be monitored by Clinical Director and be in compliance 6/18/21. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of employee records, the facility failed to provide documentation Employee #3 had at least 25 clock hours of training annually.
Employee # 3 was hired as a counselor on June 18, 2018 and was still in this position at the time of the inspection. The facility's training year from July 1, 2019 through June 30, 2020 was reviewed. Employee #3 did not document the required 25 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Staff will be scheduled for a minimum of 25 hours annually. Employee #3 is scheduled for training on 6/17-18/21 and will be in compliance for training hours this current training year (7/1/20-6/30/21). All Clinical staff will be scheduled for minimum of 25 training hours per year. This will be done by the Clinical Director. Compliance will be done as of 6/30/21 |
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 a review of the fire drill logs, the facility failed to conduct a fire drill during sleeping hours.
Fire drill logs were reviewed from June 2020 to April 2021. The facility sleeping hours are midnight - 7:45 am. At the time of the inspection, no fire drills during sleeping hours have been documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Overnight staff will conduct overnight fire drills during client sleep hours (midnight-745am) Overnight staff were trained in procedures for conducting fire drills. This will be monitored by the project Director. we will be in compliance 6/30/21 |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to disclosure of information in one of seven client records reviewed.
Client # 6 was admitted on May 6, 2021. The client record did not include a release of information form for the laboratory, but information was disclosed. Documentation in the client record included a report on May 15, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained in filling out consent forms in an in-service which is scheduled for 6/25/21. Staff will be trained on obtaining voluntary consent prior to release of information to any entity. This will be monitored by Clinical Director and in compliance as of 6/30/21. |
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 indicate the specific information to be disclosed on the release of information forms in one of seven client records reviewed.
Client #1 was admitted on January 19, 2021 and discharged on February 22, 2021. The client record included a release of information form for another government agency that was signed on January 19, 2021. The release form did not identify the specific information to be disclosed. Documentation in the client record indicated information was disclosed on January 20, February 7, 16 and 22, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained in consent form documentation when releasing information to have the specific information to be released on the consent. Training is scheduled for 6/23/21. This will be monitored by the Clinical Director. We will be in compliance by 6/30/21 |
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 client on release of information forms for two of seven client records.
Client #3 was admitted on February 5, 2021 and discharged on March 5, 2021. A release of information form for a funding source was signed by the client but did not include a date of the signature.
Client #5 was admitted on May 3, 2021. The client record included four release of information forms for funding source, emergency contact and government agencies that were signed by the client but did not include a date of the signature.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained in appropriate procedure for filling out consent forms and making sure the client signs and dates the consent form. Training will occur on 6/23/21. Clinical Director will monitor for compliance. We will be in compliance as of 6/23/21. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the date on the witness signature on release of information forms for two of seven client records.
Client #3 was admitted on February 5, 2021 and discharged on March 5, 2021. A release of information form for a funding source was signed by the witness but did not include a date of the signature.
Client #5 was admitted on May 3, 2021. The client record included four release of information forms, for funding source, emergency contact and government agencies, that were signed by the witness but did not include a date of the signature.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will attend scheduled training on 6/23/21 for filling out consent forms, including purpose and procedure for having the witness date the consent by their signature. This will be monitored by the Clinical Director for compliance, we will be in compliance 6/30/21 |
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 client records, the facility failed to document a copy of the consents were offered to the client in four of seven client records reviewed. Client records #3, 4, 5, and 6 included release of information forms that did not indicate a copy was offered to the client.
Client #3 was admitted on February 5, 2021 and discharged on March 5, 2021.
Client #4 was admitted on March 3, 2021and discharged on April 1, 2021.
Client #5 was admitted on May 3, 2021.
Client #6 was admitted on May 6, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained in consent form procedures including the purpose of offering the client a copy and where to indicate on the form a copy was offered to the client. This will be monitored for compliance by the Clinical Director. We will be in compliance as of 6/30/21 |
709.30 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.
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Observations
Based on a review of the policy and procedures, the facility failed to document a client rights policy and procedure than includes a procedure for (3), (4), (5), and (6). The documentation of written acknowledgement is also missing these required areas.
The procedure is missing for (3) clients have the right to inspect their own records., (4)
the right to appeal a decision limiting access to their records to the director, (5) the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records, and (6) the right to submit rebuttal data or memoranda to their own records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and Procedure manual was updated to include the procedures for 3, 4, 5, 6 of client rights. Manual was updated 6/18/21, as was the written acknowledgement. This will be monitored by the Clinical Director, we will be in compliance as of 6/18/21. |
709.32 (c) (2) 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:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection, the facility failed to store only medications in the medication refrigerator.
During the physical plant inspection, the refrigerator for medication included staff lunch/food and drink.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained on procedure for use of the refrigerator in the front office being for client medications only, and staff will be provided with refrigerator for their use. This will be monitored by the Project Director at least quarterly. We will be in compliance 6/30/21 |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to document information regarding the administration of client medications in five of seven client records.
Client #1 was admitted on January 19, 2021 and discharged on February 22, 2021.
Client #4 was admitted on March 3, 2021 and discharged on April 1, 2021.
Client #5 was admitted on May 3, 2021.
Client #6 was admitted on May 6, 2021.
Client #7 was admitted on May 9, 2021.
In client records #1, #4, #5, #6, and #7, the client was prescribed medications. According to the medication administration records for each client, there were gaps in which the client did not receive the medication as prescribed - missing doses or entire days. Based on the medication administration record, it is unclear if the client refused medications, or if the facility staff did not offer them to the client. There was no documentation to indicate what occurred with the missing doses.
None of the MAR ' s reviewed included the time of day the medications were given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained on procedure for documenting when a client refuses/misses a medication, and where this is to be documented on the MAR. Training will occur 6/23/21. This will be monitored by the clinical director. We will be in compliance 6/23/21 |
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 administrative information, the facility failed to document a written unusual incident report was submitted to the Department within 3 business days following an incident involving ambulance personnel.
Ambulance was called to the facility on February 10, 2021. As of the date of the inspection, there was no documentation an unusual incident report was submitted to the Department.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 29, 2020 inspection.
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Plan of Correction
Reporting of incidents involving EMS will be reported to DDAP according to the procedure for reporting incidents. Staff will be trained in procedure for filing incident reports in the Project Directors box so he can follow up with them in a timely manner. This will be monitored by the Project Director and we will be in compliance 6/17/21 |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling on a regular and scheduled basis in three of seven client records. Client Record #5, 6, 7 did not document any progress notes or entries on the record of service to indicate treatment services were provided according to the daily programming schedule for May 10 and 11, 2021.
Client #5 was admitted on May 3, 2021.
Client # 6 was admitted on May 6, 2021.
Client #7 was admitted on May 9, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will document on progress notes and record on the record of services all group and individual counseling services they perform. This will be reviewed in an in-service training on 6/23/21. Clinical Director will monitor, and will be in compliance as 6/23/21 |
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 client records, the facility failed to document a case consultation in four of four client records reviewed.
Client #1 was admitted on January 19, 2021 and discharged on February 22, 2021.
Client #2 was admitted on February 2, 2021 and discharged on March 2, 2021.
Client #3 was admitted on February 5, 2021 and discharged on March 5, 2021.
Client #4 was admitted on March 3, 2021and discharged on April 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients will have a documented case consultation note in their chart within the first two weeks of treatment. Counselors will be trained on this on 6/23/21. This will be monitored by the Clinical Director. We will be in compliance as of 6/23/21 |