INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 21, 2014 and April 22, 2014, by staff from the Program Licensure Division. Based on the findings of the on-site licensing 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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704.7(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 ensure that each counselor met the qualifications for the position in one of five personnel records reviewed.
The findings include:
Five clincial personnel records were reviewed on April 21, 2013. The facility failed to ensure that employee # 1 met the educational requirements for the position of counselor.
Employee #1 was hired as a bachelor's level counselor on September 9, 2013. Employee #1 did not meet the qualifications for the position of counselor as they did not have a bachelor's degree with an approved major.
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Plan of Correction
Employee #1's job classification is now Counselor's Assistant, beginning 4/22/14, and supervised by the Clinical Director until employee #1 attains full certification and/or Master's Degree, which is currently being pursued. Supervision will begin immediately.
The Clinical Director will determine that any counselor employed at PMRC will have valid credentialing and education within the requirements stipulated by the Commonwealth of Pennsylvania. All prospective candidates for the position of counselor will meet the Pennsylvania requirements to be a counselor prior to being hired for that specific position, and these credentials will be corroborated with the Pennsylvania Certification Board or the appropriate licensing agency and educational institution. |
709.32(c)(7) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(7) Medication errors and drug reactions.
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Observations
Based on a review of client medication administration records, the facility failed to document the administration of client medications as prescribed in four of thirty-one records reviewed.
The findings include:
Thirty-one client medication administration records were reviewed on April 21, 2014. The facility failed to document the administration of client medications in client records #1, #2, #3 and #4.
Client #1 had written orders to receive 100mg of Lamicta two times per day and 75mg of Plavix once per day. The facility failed to document the administration of the following medications on the following dates and times:
100mg - 4/15/14 at 9:00pm; 4/16/14 at 7:00am
75mg - 4/16/14 at 7:00am; 4/17/14 at 7:00am
Client #2 had a written order to receive 20mg of Inderal two times per day. The facility failed to document the administration of the following medication on the following dates and times:
20mg - 4/8/14 at 5:00pm; 4/9/14 at 5:00pm; 4/12/14 at 5:00pm
Client #3 had written orders to receive 666mg of Campral three times per day, 300mg of Neurontin three times per day, and 10mg of Claritin once per day. The facility failed to document the administration of the following medications on the following dates and times:
666mg - 4/1/14 at 3:00pm; 4/7/14 at 9:00pm; 4/10/14 at 3:00pm
300mg - 4/1/14 at 3:00pm
10mg - 4/16/14 at 7:00am
Client #4 had written orders to receive one dose of 0.1mg of Clonidine every 12 hours on 4/21/14 and one dose of 0.1mg of Clonidine once on 4/22/14. The facility failed to document the administration of the aforementioned medications on 4/21/14 and 4/22/14.
The facility director confirmed this finding.
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Plan of Correction
During a nurses' staff meeting, conducted by the Nurse Manager, on 4/24/14, all nurses were informed that they will review all patient charts before the end of each shift to ensure all medication dispense has been logged. This will also be reviewed daily by the Nurse Manager. This procedure ongoing has now been implemented. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of a client record and an interview with the facility director and the facility's IT specialist, the facility failed to obtain an signed consent to treatment for all clients.
The findings include:
Client #5's record contained a consent to treatment form that had a pin number in place of the client signature. The facility director and the facility's IT specialist stated the facility utilizes an electronic record system whereby a four digit pin number is assigned to the client for the purpose of electronically signing intake documents.
The facility director confirmed the findings.
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Plan of Correction
PMRC is submitting to the department of drug and alcohol program licensing a letter of consideration\exemption, to continue the use of an electronic pin pad as a viable option for patient signatures. We are also contacting the software design department of "Best Notes" for their adaptability of a signature pad in place of the secured pin pad. Until this exemption approval or denial, or determination of compatibility with the signature pad is resolved, the clinical director and executive director are implementing the following to meet the licensure standards:
All forms requiring patient signatures will be printed and reviewed with the patient; upon their understanding, the patient and staff will physically sign their signature to the required paperwork. The signed forms will then be scanned into their secured patient electronic chart. The original signed paperwork will be placed into a physical patient chart, which will be maintained at the nurse's station. This will be effective immediately and staff training will be conducted on
5\26\2014 on the previously defined procedure. Until this time, beginning
5\23\2014 the intake staff, along with therapy staff have been instructed on this procedure, by the clinical director and executive director.
The following documents that will be included in the physical signing by the patient and staff are as follows: Consent to treatment, the voluntary application, authorization for emergency medical treatment, drug-free admission form, patient confidentiality notice, patient responsibilities, policy or drug testing, program rules, guidelines for involuntary discharge, behavioral contract, grievance that appeals, grievance procedure, client's rights, consent to photograph, assignment of benefits, coordination of benefits, consent to release information, personal belongings\valuables list, aftercare for, discharge against clinical advice, treatment plans, updated treatment plants, discharge medication, medication patient teaching, primary care consent form and all other paperwork requiring patient signatures.
Clinical director and executive director will monitor this process daily with new admissions. Patients that are already in treatment, the clinical director and executive director will ensure that every therapist will have the appropriate documentation signed by the patient as needed and within the standards. This procedure will be an ongoing process.
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