INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23-24, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of two applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client # 7 was admitted to the inpatient non-hospital detoxification activity on August 20, 2024, and was discharged against medical advice on August 23, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #13 was admitted to the inpatient non-hospital rehabilitation activity on September 2, 2024 , and was discharged against medical advice on September 20, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services or designee will conduct a mandatory training of all inpatient counselors to ensure that staff understand, notify, and document outreach to the EMC in the event of a client's AMA/ACA discharge. The training will be completed by 11/15/2024.
The Director of Clinical Services or designee will retain the training certificates and/or training signature sheets and will provide copies to the Director of Q&PI by 11/30/2024.
Compliance will be regularly monitored by the Medical Records Clerk and/or the Director of Clinical Services or designee. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven partial hospitalization client records, the facility failed to provide at least two individual session a week in four out of seven client records.
Client #15 was admitted on June 3, 2024 and was still active at the time of the inspection. The client has only been receiving one individual session a week since August 24, 2024.
Client #16 was admitted on August 12, 2024 and was still active at the time of the inspection. The client has only been receiving one individual session a week since August 13, 2024.
Client #17 was admitted on August 29, 2024 and was still active at the time of the inspection. The client only received one individual session weekly from September 1st through September 16, 2024.
Client #20 was admitted on May 14, 2024 and was discharged on June 24, 2024. The client only received on individual session weekly from May 22, 2024 until June 18, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 5, 2023 licensing inspection .
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Plan of Correction
The Director of Clinical Services or designee will conduct a mandatory group supervision of all outpatient counselors to re-educate and reinforce the requirement of providing a minimum of two individual sessions per week, including coverage in the event that the primary counselor is not present in a given week. The supervision will occur by 11/15/2024.
The Director of Clinical Services or designee will document and description of the supervision and retain this along with the attendance signature sheets. They will provide copies of the description and attendance to the Director of Q&PI by 11/30/2024.
Compliance will be regularly monitored by the Medical Records Clerk and/or the Director of Clinical Services or designee.
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709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of three applicable discharged records reviewed.
Client #19 was admitted on March 14, 2024 and was discharged on June 14, 2024. No aftercare was documented in the client record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient program has added a case manager position to the department. Among other tasks, they will be responsible for completing and documenting all aftercare plans with the clients. In their absence (vacation, etc.), the Manager of Clinical Services will perform this task. The Director of Clinical Services, the Medical Records Clerk, and/or designee will monitor for compliance on a weekly basis.
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709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on a review of partial hospitalization client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three discharged records reviewed.
Client #19 was admitted on March 14, 2024 and was discharged on June 14, 2024. No follow up information was documented at the time of the inspection.
Client #20 was admitted on May 14, 2024 and was discharged on June 24, 2024. No follow up information was documented at the time of the inspection.
Client #21 was admitted on July 11, 2024 and was discharged on August 8, 2024. No follow up information was documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 5, 2023 and December 5, 2023 licensing inspections.
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Plan of Correction
The outpatient program has added a case manager position to the department. Among other tasks, they will be responsible for completing and documenting all aftercare follow-up calls with the clients. In their absence (vacation, etc.), the Manager of Clinical Services will perform this task. The Clinical Director or designee will monitor this for compliance on a weekly basis.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting follow-up information for the outpatient records was submitted and approved by the Department for the February 6, 2023 and December 28, 2023 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the September 23-24, 2024 licensing inspection.
This finding was discussed with facility staff duirng the licensing process.
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Plan of Correction
Compliance will be regularly monitored by the Medical Records Clerk and/or the Director of Clinical Services or designee. Findings will be reported to the Facility CEO to determine the action step for any deficiencies.
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