INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2020 through January 29, 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, Pennsylvania 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The facility failed to provide documentation that employee #3, an intern with a client caseload who was hired on October 1, 2019, was properly supervised by a full-time clinical supervisor or a qualified counselor.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide 1 hour of individual supervision per week to each member of the clinical staff in addition to the Clinical Supervisor, providing 1 hour of clinical supervision per week to all clinical staff. All supervisions will be documented and kept in the employees' file. Program Director will review supervision hours 1x monthly for audit purposes.
Page 63 of Policies and Procedures
3. All clinical services and clinical staff members will be supervised by a clinical supervisor and/ or program director deemed qualified per the verification of education and experience as outlined in 28 Pa. Code 704.6
- There must be (1) Clinical Supervisor for every (8) full time counselors or counselor assistants
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The facility failed to provide documentation that employee #3, an intern with a client caseload hired on October 1, 2019, counseled clients under the close supervision of a clinical supervisor or trained counselor for at least the first six months in the position.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct a clinical supervision audit 1x monthly and track required supervision hours for each member of the clinical staff. A running Excel Spreadsheet will be kept digitally and available upon request.
3.All clinical services and clinical staff members will be supervised by a clinical supervisor and/ or program director deemed qualified per the verification of education and experience as outlined in 28 Pa. Code 704.6
- There must be (1) Clinical Supervisor for every (8) full time counselors or counselor assistants
1 hour supervision per week by Clinical Supervisor
1 hour per week by Program Director,
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation of an individual training plan, developed with input from both the employee and the supervisor, for three employees reviewed.
Employee #1 was hired as the project/facility director on 12/31/19
Employee #2 was hired as a counselor on 12/2/19
Employee #3 was hired as an intern on 10/1/19
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Program Director will have each new employee complete a "New Employee" checklist for all staff and/ or required clinical trainings. This will be completed and signed by both the Program Director or Clinical Supervisor and kept in employee files.
Each staff member will meet with Clinical Supervisor and Program Director annually for a performance review from start date. At that time each employee will be evaluated and given an opportunity to collaborate on trainings/ education for professional growth in specified domains. Annual reviews will be signed by employee and Program Director or Clinical Supervisor and kept in employee files.
Page 32 of Policies and Procedures
Policy
It is the policy of Pennsylvania Recovery Center to ensure that all new hires complete mandatory training requirements within 90 days of hire date; with documented completion dates of trainings, training providers, number of hours received, and expiration date in the employee file unless otherwise specified based on previous completion dates related to CEUs. Each employee will be required to submit a written summary on each training. This will be reviewed annually for each employee by Program Director or direct supervisor. Furthermore Program Director or direct supervisor will develop annual training plans ( Calendar year) for each position, which could require additional trainings for identified areas of needed improvement.
Procedure
Required Training:
1. HIV/ AIDS & TB/ STD: Required Infectious Disease Training (Curriculum must follow both Licensing Alerts 1-97 & 6-97)
2. CPR Certification
3. First Aid Training
Annual Training Requirements
Program Director- 12 hours
Facility Director- 12 hours
Clinical Supervisor/ Lead Counselor- 12 hours
Counselor- 25 hours
Counselor Assistant- 40 hours within first year, 30 hours for each following year
Page 36 of Policies and Procedures
2. The Program Director in collaboration with Clinical Supervisor, will create an individual training plan for all new hires to direct and ensure that all staff receive the appropriate training.
3. Training requirements and staff qualifications are outlined in the written Compliance and Staff Development plan that is reviewed and approved annually be leadership (see full plan in leadership binder).
4. The plan will include the qualifications and training of all staff as outlined in 28 Pa Code 704.3-704.11.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to ensure that all reviewed employees had obtained fire extinguisher training upon employment. There was no documentation provided by the facility at the time of the inspection.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All current employees will have documented fire extinguisher training documented in employee file. All new employees will be fire extinguisher trained within the first 48 hours of start date and the training will be documented in employee file.
Program Director will ensure all required staff trainings for new employees are completed, documented, signed-off by employee and Program Director within designated time-frames. This document, when completed, will include a checklist of staff trainings and will be located in employee files. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to ensure that all reviewed employees had obtained emergency preparedness training. There was no documentation provided by the facility at the time of the inspection. Additionally, the facility failed to identify on their fire drill log the number of people in the facility at the time of the drill and which exit route was used during every drill conducted in April 2019 thorugh December 2019.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All current employees will have emergency preparedness training completed and documented in employee file. All new employees will complete emergency preparedness within 48 hours from start date and with documented completion placed in employee file.
Moving forward, all monthly fire drills and emergency drills will be logged. The log will include the date of the drill, type of drill, the number of people in the facility at the time of the drill, which exit route was used, and the time it took for all people to reach designated location away/ outside of the building.
Program Director will complete an audit of required emergency preparedness training for all current and new employees monthly, this will be included on the new employee checklist, signed off by Program Director and Employee and placed in each employee file. Furthermore, Program Director will ensure all drills are documented properly with required information and will keep a 3-ring binder located in the office of the CEO, available upon request. Clinical Staff is responsible for documenting any emergency/ fire drills on site in the 3-ring binder. |
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
The facility failed to obtain an informed and voluntary consent to release information form to the client's funding source in every client record reviewed.
These findings were discussed with facility staff during the licensing process
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Plan of Correction
Electronic Records System Provider: Kipu, has made the release of information for client funding source accessible and all staff has been trained to complete this consent with all clients entering treatment during the intake/ informed consent process.
Program Director and Clinical Supervisor will complete weekly chart audits to ensure all required forms and documentation are completed and signed-off on by required times as designated in PARC Policy & Procedures. |
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
The facility failed to ensure that all informed and voluntary consent to release information forms to a government agency were kept within the restrictions of 4 PA code 255.5 in one of seven client record reviewed.
Client #1 was admitted on July 8, 2019 and was active at the time of inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All staff has been retrained to complete informed and voluntary consent to release information forms to a government agency while completing intake process of all new clients. All forms will be located in client chart and kept in confidential electronic medical record system: Kipu
All consents will expire after 1 calendar year unless directed otherwise by the client.
Program Director and Clinical Supervisor will complete weekly chart audits to ensure all required forms and documentation are completed and signed-off on by required times as designated in PARC Policy & Procedures. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing, of the decision to involuntarily terminate the client from treatment in three of seven client records reviewed.
Client #4 was admitted on May 20, 2019 and was discharged November 15, 2019.
Client #5 was admitted on August 1, 2019 and was discharged January 3, 2020.
Client #6 was admitted on September 26, 2019 and was discharged December 19, 2019
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will send a typed letter to any client that is involuntarily terminated from the treatment program, detailing reason(s) for the termination. This letter will be sent within 48 hours of the decision to involuntarily terminate and documented in the client record.
Program Director will ensure this requirement is completed in weekly chart audits in addition to all other required forms and documentation that are to be completed and signed-off on by required times as designated in PARC Policies & Procedures. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
The facility failed to give the client the opportunity to request reconsideration of the decision to terminate treatment in three of seven client records reviewed.
Client #4 was admitted on May 20, 2019 and was discharged November 15, 2019.
Client #5 was admitted on August 1, 2019 and was discharged January 3, 2020.
Client #6 was admitted on September 26, 2019 and was discharged December 19, 2019.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will send a typed letter to any client that is involuntarily terminated from the treatment program, detailing reason(s) for the termination. This letter will be sent within 48 hours of the decision to involuntarily terminate and documented in the client record.
This letter will also include information that details a client's ability to submit a written request for reconsideration of the decision to involuntarily terminate. This request will be reviewed and considered by the Program/ Project Director and the clinical staff.
Program Director will ensure this requirement is completed in weekly chart audits in addition to all other required forms and documentation that are to be completed and signed-off on by required times as designated in PARC Policies & Procedures. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in six of seven client records reviewed.
Client #1 was admitted on July 8, 2019 and was active at the time of inspection. A treatment plan update was completed on August 8, 2019 and a treatment plan update was due no later than October 8, 2019. However, the update was not completed at the time of inspection.
Client #2 was admitted on October 25, 2019 and was active at the time of inspection. A comprehensive treatment plan was completed on October 28, 2019 and a treatment plan update was due no later than December 28, 2019. However, the update was not completed at the time of inspection.
Client #4 was admitted on May 20, 2019 and was discharged November 15, 2019. A treatment plan was completed on September 6, 2019 and a treatment plan update was due no later than November 6, 2019. However, the update was not completed at the time of inspection.
Client #5 was admitted on August 1, 2019 and was discharged January 3, 2020. A comprehensive treatment plan was completed on August 3, 2019 and a treatment plan update was due no later than October 3, 2019. However, the update was not completed at the time of inspection.
Client #6 was admitted on September 26, 2019 and was discharged December 19, 2020. A comprehensive treatment plan was completed on September 30, 2019 and a treatment plan update was due no later than November 30, 2019. However, the update was not completed at the time of inspection.
Client #7 was admitted on August 12, 2019 and was discharged November 12, 2020. A comprehensive treatment plan was completed on August 16, 2019 and a treatment plan update was due no later than October 16, 2019. However, the update was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will oversee all charting/ documentation within the electronic medical record and perform weekly audits in addition to daily top-signing responsibilities of all required documentation. This includes but is not limited to Initial Treatment Plans, Master Treatment Plans, and Treatment Plan Updates.
The Program Director developed an audit system to track all client charting/ documentation is completed within the required time-frames. The audit system will be utilized each week for all clients.
The Program Director will ensure this requirement is completed in weekly chart audits in addition to all other required forms and documentation that are to be completed and signed-off on by required times as designated in PARC Policies & Procedures. |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
The facility failed to have a complete client record, which is to include case consultation notes, aftercare plans and follow-up information, in four of seven client records reviewed.
Client #4 was admitted on May 20, 2019 and was discharged November 15, 2019. There was no documentation of any case consultations, an aftercare plan, and a discharge summary.
Client #5 was admitted on August 1, 2019 and was discharged January 3, 2020. There was no documentation of any case consultations.
Client #6 was admitted on September 26, 2019 and was discharged December 19, 2019. There was no documentation of any case consultations.
Client #7 was admitted on August 12, 2019 and was discharged November 12, 2019. There was no documentation of any case consultations and any follow-up information.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will oversee all charting/ documentation within the electronic medical record and perform weekly audits in addition to daily top-signing responsibilities of all required documentation. This includes but is not limited too case consultation notes (every 90 days), aftercare/ discharge planning, discharge summaries, and chart closures upon client discharge to be completed within 72 hours.
The Program Director developed an audit system to track that all client charting/ documentation is completed within the required time-frames. The audit system will be utilized each week for all clients.
The Program Director will ensure this requirement is completed in weekly chart audits in addition to all other required forms and documentation that are to be completed and signed-off on by required times as designated in PARC Policies & Procedures. |