INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Armada Recovery Pa 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(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
Based on a review of personnel records, the facility failed to ensure two counselor assistants counseled clients only under the close supervision of a trained counselor or clinical supervisor for the documented period based on their education and clinical experienceEmployee #3 was hired as a counselor assistant on October 5, 2023 and was current in that position at the time of the inspection. Employee #3 has a bachelor ' s degree from a foreign university and does not have an evaluation completed by a member of the National Association of Credential Evaluation Services (NACES); therefore Employee #3 is reviewed as having a high school diploma with no clinical experience. Employee #3 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. Employee #3 did not receive close supervision from October 5, 2023, until the inspection occurred. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " Employee #4 was hired as a counselor assistant on September 18, 2023 and was current in that position at the time of the inspection. Employee #4 has a qualifying bachelor ' s degree but does not have the one year of clinical experience. Employee #4 may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Employee #4 did not receive documented close supervision from September 18, 2023 to the date on the inspection. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency's policy has been changed to allow for the hiring of only one Counselor Assistant at any given time. The policy also includes a procedure that: Counselor assistants cannot provide any direct service, however, can participate in group sessions as a co-facilitator with a counselor as the lead. Furthermore, any counselor assistants will have a minimum of a bachelor's degree from an accredited University in the United States. |
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
Based on a review of personnel records, the facility failed to develop written individual training plans for each employee, appropriate to that employee's skill level annually with input from both the employee and the supervisor in two of three records reviewed.Employee #1 was hired as the project director and facility director on September 4, 2023 and was current in that position at the time of the inspection. There was no documentation of an individual training plan being developed.Employee #4 was hired as a counselor assistant on September 18, 2023 and was current in that position at the time of the inspection. The individual training plan was not developed until October 19, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has developed and trained staff on revised policy and procedures, which document training plans and related content that must be completed both upon hire and annually. The Director of HR will be responsible for ensuring that all training plans are part of the personnel folders; the project Director shall review supervision notes and training plans monthly. The HR Director and Project Director will monitor this corrective action activity by inspecting personnel folders, via the checklist and inspecting supervision activity, (notes, training plans, perf. evals. monthly |
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
Based on a review of three personnel records, the facility failed to ensure that two staff were instructed in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.Employee #1 was hired as the project director and facility director on September 4, 2023 and was current in that position at the time of the inspection. There was no documentation of employee #1 being instructed in the use of the fire extinguisher upon staff employment. Employee #4 was hired as a counselor assistant on September 18, 2023 and was current in that position at the time of the inspection. There was no documentation of employee #4 being instructed in the use of the fire extinguisher upon staff employment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has developed a policy mandating that the orientation training include Emergency Procedures, use of fire extinguishers, and HIV & STD education. The training will be part of our onboarding and annual training: our HR Director will make sure the trainings are completed upon hire and work jointly with our compliance officer to ensure the use of fire equipment is provided in our annual training. |
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
Based on a review of personnel records, the facility failed to ensure that two of three personnel on all shifts are trained to perform assigned tasks during emergencies.Employee #1 was hired as the project director and facility director on September 4, 2023 and was current in that position at the time of the inspection. There was no documentation of employee #1 being trained to perform assigned tasks during emergencies.Employee #4 was hired as a counselor assistant on September 18, 2023 and was current in that position at the time of the inspection. There was no documentation of employee #4 being trained to perform assigned tasks during emergencies.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our agency's policy and procedure manual mandates training upon hire on "Emergency Procedures" The policy has been reviewed with all present staff and made part of the HR Director's checklist upon hire. The HR Director and Chief Compliance Officer will monitor this activity by conducting monthly audits of training for any staff hired during the month of 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, the facility failed to obtain an informed and voluntary consent for disclosure of information contained in one of seven applicable records reviewed. Client #2 was admitted September 20, 2023 and discharged October 12, 2023. There was no informed and voluntary consent to disclose information to the client ' s funder documented in the client record. The facility reported the client had private insurance and would have been billed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has revised its intake/admissions paperwork to include Release of Information forms for supervising agencies and insurance carriers, in addition to family, and/or friends. The Project Director will ensure the completion of this citation by reviewing all new admits to ensure adherence. Note: This will be the responsibility of the Clinical Director when was is hired. |
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 whether a copy of a client consent was offered to the client and a copy maintained in three of seven applicable records reviewed. Client #3 was admitted on September 20, 2023 and administratively discharged on October 9, 2023. There was an informed and voluntary consent to disclose information form for a family member signed by the client on September 20, 2023; however, there was no documentation a copy was offered. Client #4 was admitted on September 25, 2023 and discharged on October 3, 2023. There was an informed and voluntary consent to disclose information form for a family member signed by the client on September 25, 2023; however, there was no documentation a copy was offered. Client #8 was admitted on September 30, 2023 and was still active at the time of the inspection. There was an informed and voluntary consent to disclose information form for a family member signed by the client on September 30, 2023; however, there was no documentation a copy was offered. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has revied its policy "Intake/Admission" to add procedures that the person completing the admissions complete the pertinent consent forms committing the forms to the client record, advising the client of their right to the consent forms signed; The primary counselor shall be responsible for advising and the client of his/her right to and offering the same to the client. The Project Director will monitor this activity by reviewing and signing off on all new admissions. When we hire a Clinical Director he/she will conduct this oversight activity. |
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
Based on a review of client records, the facility failed to 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 in one applicable record reviewed. Client #3 was admitted on September 20, 2023 and administratively discharged on October 9, 2023. There was no documentation of a termination letter in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our termination policy has been revised to include the following: any proposed discharges will be presented to the Project Director prior to discharge. At the time a decision is made to administratively discharge a client the client will be notified verbally and provided a written notice of the discharge grievance and appeal processes. The Project Director shall be responsible for ensuring that any clients administratively discharged receive written notice of their discharge and all related information. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to have a client orientation that included documentation of the hours of operation in nine of nine records reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The electronic health record has been revised to add hours of operation to the client's orientation process. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to have a client orientation that included documentation of the fee schedule in nine of nine records reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has revised the "Client Handbook" and added the fee schedule; additionally, the fee schedule has been added to the electronic record under the admissions forms the client signs and will be reviewed with the client upon admission. All admissions and related paperwork will be reviewed and countersigned as appropriate by the Clinical Director or Project Director in the absence of a clinical director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to follow their policy to complete psychosocial evaluations within three days of admission in four of nine records reviewed.Client #1 was admitted on September 30, 2023 and discharged on October 16, 2023. The psychosocial evaluation was due to be completed by October 3, 2023, but one was not documented. Client #4 was admitted on September 25, 2023 and discharged on October 3, 2023. The psychosocial evaluation was due to be completed by September 28, 2023, but was not documented until October 12, 2023. Client #5 was admitted on September 20, 2023 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by September 23, 2023, but was not documented until September 25, 2023. Client #8 was admitted on September 30, 2023 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed October 3, 2023; however, the psychosocial evaluation form in the record was dated October 23, 2023, and contained no information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has established a policy that all Biopsychosocials will be completed within three visits or three days, whichever occurs first, to ensure that we meet our stated goal we have added to our procedures in the admissions policy that the Clinical Director/Facility Director will assign a counselor to co0mplete the biopsychosocial following the completion of the admissions process. The Clinical Director/Project Director will conduct monthly chart audits to ensure compliance in this area. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop treatment and rehabilitation plans within their policy time frame of three days or three visits in three out of three applicable records reviewed. Client #5 was admitted on September 20, 2023 and was still active at the time of the inspection. There was no documentation of a treatment and rehabilitation plan being developed by the date of the inspection. Client #6 was admitted September 20, 2023 and was still active at the time of inspection. There was no documentation of a completed treatment and rehabilitation plan being developed by the date of the inspection. Client #9 was admitted on September 30, 2023 and was still active at the time of the inspection. There was no documentation of a completed treatment and rehabilitation plan being developed within three days or three visits. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have changed our policy to state" An initial treatment plan will be completed upon admission: Master Treatment Plan will be completed within 45 days of treatment. To ensure compliance with this policy the Clinical Director/Project Director will conduct monthly audits of charts, additionally clients will be reviewed in a bi-monthly multidisciplinary meeting. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including a record of services provided in four out of nine records reviewed. Client #1 was admitted on September 30, 2023 and discharged on October 16, 2023. The client record did not have a record of service documented. Orientation paperwork was signed on the day of admission however there was no other information relative to the client's involvement with the project in the record. Client #2 was admitted September 20, 2023 and discharged October 12, 2023. The client record did not have a record of service documented. Orientation paperwork was signed on the day of admission however there was no other information relative to the client's involvement with the project in the record. Client #3 was admitted on September 20, 2023 and administratively discharged on October 9, 2023. The client record did not have a record of service documented. Orientation paperwork was signed on the day of admission however there was no other information relative to the client's involvement with the project in the record. Client #4 was admitted on September 25, 2023 and discharged on October 3, 2023. The client record did not have a record of service documented. Orientation paperwork was signed on the day of admission however there was no other information relative to the client's involvement with the project in the record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and/or Clinical Director have both reviewed the agencies policy on the Performance Improvement Plan their responsibility to audit client 20 percent of all client records monthly. The Performance Improvement Plan has been reviewed with the counseling staff including the facilities expectations of recordkeeping responsibilities. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including, progress note in five of nine records reviewed.Client #1 was admitted on September 30, 2023 and discharged on October 16, 2023. There were no documented progress notes in the record. Client #2 was admitted September 20, 2023 and discharged October 12, 2023. There were no documented progress notes in the record.Client #3 was admitted on September 20, 2023 and administratively discharged on October 9, 2023. There were no documented progress notes in the record.Client #4 was admitted on September 25, 2023 and discharged on October 3, 2023. There were no documented progress notes in the record.Client #9 was admitted on September 30, 2023 and was still active at the time of the inspection. An individual counseling session dated October 23, 2023 had a progress note that was started with the information to be discussed but the rest of the note was incomplete.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has reviewed the facilities Performance Improvement Plan and Quality Assurance Plans with the staff detailing the agencies recordkeeping standards, the staff's responsibilities related to record keeping and the review process. The Performance Improvement and quality assurance plans will also be reviewed with staff during orientation and annually. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes. The facility ' s policy indicates a case consultation is to be completed upon admission. A case consultation was not documented in nine out of nine records reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The staff has been educated on the agencies "Case Consultation" policy has been reviewed with all staff to ensure compliance with our policy following admission the person completing the admission will present the client to the treatment team in our morning consultation meeting to the treatment team. The policy has been updated to say that will hold a morning briefing meeting daily to review admissions, potential discharges, and any other pertinent information on the treatment population. The Project Director, in the absence of a Clinical Director, will be responsible for ensuring consultation notes are placed in the client folder, this will be monitored by monthly chart audits and weekly team meetings. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary in three of three applicable records reviewed. Client #1 was admitted on September 30, 2023 and discharged on October 16, 2023. There was no documented discharge summary in the record. Client #2 was admitted September 20, 2023 and discharged October 12, 2023. There was no documented discharge summary in the record.Client #3 was admitted on September 20, 2023 and administratively discharged on October 9, 2023. There was no documented discharge summary in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our policy has been revised to state that the chart for any discharges will be reviewed by the Clinical or Project Director within 72 hours of discharge for
compliance with our policy of summaries for discharge and completion of the pertinent information. The Project Director and/or Clinical Director will be responsible for monthly audits of all discharged charts to ensure adherence to this policy. |