INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2 - 3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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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 on December 3, 2020, the facility failed to maintain bathrooms in a clean and sanitary manner. The shower in room 112 was observed to be dirty.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Facility Operations or their designee will inspect 8 patient bathrooms a month (2 a week) randomly. The inspections will take place for 6 months. An attestation of inspection will be completed monthly. There will be ongoing random inspections at least once a month for a year with an attestation. |
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
A review of the January 2020 through November 2020 fire drill logs was conducted during the onsite inspection. The facility failed to conduct a fire drill during sleeping hours at least every six months. A sleeping fire drill was conducted on October 29, 2019 with the next one done on July 31, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire safety drills will be scheduled for the year. The plan will be reviewed fir compliance with 705.10 (d)(5).
Documentation of the day, time, and participants (staff and patients) will be kept and available for DDAP inspection. |
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 on December 2-3, 2020, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #14 and 16.
Client #14 was admitted on March 6, 2020 and discharged on June 15, 2020. A progress note dated June 15, 2020 stated that information was disclosed to a government agency outside the parameters set by 4 Pa. Code 255.5(b).
Client #16 was admitted on May 28, 2020 and discharged on September 4, 2020. The consent to release information form dated June 4, 2020 to a government agency permitted the release of psychiatric evaluation, discharge summary, discharge instructions and continuing care plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28: All staff that are required to complete a consent form will receive advanced training including a quiz to assure that they are competent.
After validating competency consents will be audited by Risk Manager. Ten consents will be audited each month. Feedback on completion of the consents will be provided to the Director of Admissions, Director of Clinical Services, and Director of Nursing. The CEO will be informed of the audit results monthly.
Staff that do not complete consents but might be asked about a client i.e. drivers and behavior health associates will be retrained on confidentiality 255.5 (b). |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records on December 2-3, 2020, the facility failed to document a completed consent to release information form in client record #15, as the form was missing to whom disclosure may be made.
Client #15 was admitted on January 22, 2020 and discharged on June 21, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28: All staff that are required to complete a consent form will receive advanced training including a quiz to assure that they are competent.
After validating competency consents will be audited by Risk Manager. Ten consents will be audited each month. Feedback on completion of the consents will be provided to the Director of Admissions, Director of Clinical Services, and Director of Nursing. The CEO will be informed of the audit results monthly.
Staff that do not complete consents but might be asked about a client i.e. drivers and behavior health associates will be retrained on confidentiality 255.5 (b). |
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 the review of client records on December 2-3, 2020, the facility failed to document a completed consent to release information form in client #8, as the form was missing what specific information could be disclosed.
Client #8 was admitted on November 17, 2020 and was still active at the time of the inspection. The consent to release information dated November 20, 2020 was to a healthcare facility.
The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 24, 2020 licensing inspection.
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Plan of Correction
709.28: All staff that are required to complete a consent form will receive advanced training including a quiz to assure that they are competent.
After validating competency consents will be audited by Risk Manager. Ten consents will be audited each month. Feedback on completion of the consents will be provided to the Director of Admissions, Director of Clinical Services, and Director of Nursing. The CEO will be informed of the audit results monthly.
Staff that do not complete consents but might be asked about a client i.e. drivers and behavior health associates will be retrained on confidentiality 255.5 (b). |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records on December 2-3, 2020, the facility failed to document a completed consent to release information form in clients # 6 and 8, as the form was missing purpose of disclosure
Client #6 was admitted on November 10, 2020 and was still active at the time of the inspection. The consent to release information form dated November 10, 2020 was to an outside entity.
Client #8 was admitted on November 17, 2020 and was still active at the time of the inspection. The consent to release information form dated November 20, 2020 was to a healthcare facility.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 24, 2020 licensing inspection.
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Plan of Correction
709.28: All staff that are required to complete a consent form will receive advanced training including a quiz to assure that they are competent.
After validating competency consents will be audited by Risk Manager. Ten consents will be audited each month. Feedback on completion of the consents will be provided to the Director of Admissions, Director of Clinical Services, and Director of Nursing. The CEO will be informed of the audit results monthly.
Staff that do not complete consents but might be asked about a client i.e. drivers and behavior health associates will be retrained on confidentiality 255.5 (b). |