INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of six applicable personnel records.
Employee # 6 was hired as the director of admissions on May 16, 2019. The TB/STD training was due to be completed no later than May 16, 2021; however, TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the January 13, 2022 and January 19, 2023 annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer has identified a 30 day training window for all indicated staff/ employees to be fully trained in 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics.
Employees 6 has completed the training, he has been unable to gain a copy of his certificate. He contacted his former employer and we are waiting to hear back. If unable to retain a copy, he will complete the required training, first available training approved by DDAP.
The certificates for training completions will be placed in the respective employee files and all current and future employee files will be reviewed in the weekly DDAP Compliance Management Meetings. |
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 personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in one of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on May 1, 2023. The training in the use of fire extinguishers was not completed until June 20, 2023.
This is a repeat citation from the January 19, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 All new employees will be trained on fire safety protocol, which includes operation of fire extinguishers within the first week after initial hire date. Chief Clinical Officer will review personal records (new & existing) during the weekly DDAP management and compliance meetings. |
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 all personnel on all shifts were trained to perform assigned tasks during emergencies in one of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on May 1, 2023. The training in tasks to perform during emergencies was not completed until June 20, 2023.
This is a repeat citation from the January 19, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 All new employees will be trained on emergency protocols and assigned tasks during emergencies within the first week after initial hire date. Chief Clinical Officer will review personal records (new & existing) during the weekly DDAP management and compliance meetings. |
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 client records, the facility failed to ensure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in all client records reviewed.
Client #1 was admitted to the partial hospitalization activity on March 16, 2023 and was discharged on May 1, 2023. The record's progress notes indicated that the client received one individual session on March 28, 2023, for the week of March 26, 2023 through April 1, 2023, and one individual session on April 20, 2023, for the week of April 16, 2023 through April 22, 2023.
Client #2 was admitted to the partial hospitalization activity on March 20, 2023 and was discharged on May 1, 2023. The record's progress notes indicated that the client received one individual session on April 28, 2023, for the week of April 23, 2023 through April 29, 2023.
Client #3 was admitted to the partial hospitalization activity on April 4, 2023 and was discharged on May 24, 2023. The record's progress notes indicated that the client received two individual sessions on May 10, 2023 and May 18, 2023, for the weeks of May 7, 2023 through May 20, 2023.
Client #4 was admitted to the partial hospitalization activity on March 23, 2023 and was discharged on May 5, 2023. The record's progress notes indicated that the client received one individual session on March 27, 2023, for the week of March 26, 2023 through April 1, 2023, and one individual session on April 18, 2023, for the week of April 16, 2023 through April 22, 2023.
Client #5 was admitted to the partial hospitalization activity on April 10, 2023 and was discharged on June 6, 2023. The record ' s progress notes indicated that the client received five individual sessions on April 28, 2023, May 5, 2023, May 18, 2023, May 25, 2023 and June 1, 2023 for the weeks of April 23, 2023 through June 3, 2023.
Client #6 was admitted to the partial hospitalization activity on June 22, 2023 and was active at the time of inspection. The record ' s progress notes indicated that the client received one individual session on July 3, 2023, for the week of July 2, 2023 through July 8, 2023.
Client #7 was admitted to the partial hospitalization activity on June 23, 2023 and was active at the time of inspection. The record ' s progress notes indicated that the client received one individual on June 26, 2023, for the week of June 25, 2023 through July 1, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients receiving care in ASAM 2.5, Partial Hospitalization Programming will receive a minimum of two individual counseling services per week. Clinical Supervisor will audit all client records on a weekly basis to ensure clients in ASAM 2.5 are receiving a minimum of two individual counseling sessions per week. The Clinical Supervisor will report her findings to Chief Clinical Officer during the scheduled weekly DDAP management & compliance meetings to assure the all ASAM 2.5 (PHP) clients are receiving the regulated frequency of care per week, 2 individual sessions as previously defined in this plan of correction. |
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 document that the individual treatment and rehabilitation plan was developed with the client and/or completed according the facility policy and procedure in three of five applicable client records reviewed.
The facility's policy and procedure manual stated that the comprehensive treatment and rehabilitation plan will be completed within 30 days of admission.
Client #8 was admitted to the outpatient activity on May 1, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was due no later than June 1, 2023; however, the plan was completed on June 21, 2023.
Client #9 was admitted to the outpatient activity on May 1, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was due no later than June 1, 2023; however, the plan was completed on June 23, 2023.
Client #12 was admitted to the outpatient activity on April 5, 2023 and was discharged on June 30, 2023. The individual treatment and rehabilitation plan was due no later than May 5, 2023; however, the plan was completed on June 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will audit all clinical charts bi-weekly to ensure completion of individualized comprehensive treatment and rehabilitations plans. Clinical Supervisor will report her findings to Chief Clinical Officer during weekly DDAP management & compliance meetings. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.
Client #11 was admitted to the outpatient activity on June 6, 2023 and was discharged on June 16, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.
Client #13 was admitted to the outpatient activity on April 3, 2023 and was discharged on April 21, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.
Client #14 was admitted to the outpatient activity on April 24, 2023 and was discharged on June 13, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.
This is a repeat citation from the January 19, 2023, January 13, 2022, and January 12, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BHT Support Staff has started contacted previously discharged clients as part of of our alumni/ follow-up tracking based on our Policy & Procedures. BHT Support Staff will relay on phone calls to clients at 30, 60, 90, 120, and 365 days post discharge for alumni/ follow-up contact to assess efficacy of program and client stability post-discharge. Brief Assessments of Recovery Capital (BARC-10) will be conducted during these phone calls. If the client is unreachable an alumni/ follow-up letter will be sent with instructions to contact the facility and complete a BARC-10. A copy of the letter will be upload into each chart with date. time of letter sent. If an alumni/ follow-up call is successful it will be documented in each client chart. Clinical Supervisor will include alumni/ follow-up attempts and documentation during bi-weekly chart audits and will report her findings to Chief Clinical Officer during weekly DDAP management & compliance meetings. |
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 administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure that all staff persons received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe was submitted and approved by the Department for the January 19, 2023 and January 13, 2022 annual licensing inspections. Failing to ensure that all staff persons received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe was again found to be a deficiency in the July 19, 2023 provisional follow-up licensing inspection.
A plan of correction for obtaining follow-up information was submitted and approved by the Department for January 19, 2023, January 13, 2022, and January 12, 2021 annual licensing inspections. Not obtaining follow-up information was again found to be a deficiency in the July 19, 2023, provisional follow-up licensing inspection.
This is a repeat citation from the January 19, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer has identified a 90 day training window for all indicated staff/ employees to be fully trained in 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics.
The certificates for training completions will be placed in the respective employee files and all current and future employee files will be reviewed in the weekly DDAP Compliance Management Meetings by Chief Clinical Officer. All staff without these two required trainings will have 90 days to retain certificates from previously completing these trainings or schedule and complete these two required trainings.
Chief Clinical Officer and Clinical Supervisor were briefed by DDAP Agent about the possibility of having our PA License 91C86601 changed to provisional due to repeated citations. We take this potential consequence very seriously.
Chief Clinical Officer has established weekly meetings with the management team and ownership to address DDAP regulations, Status of Plans of Correction, Compliance, Updates to P & P, staff and facility training plans, etc.
These weekly meetings, held at 1:30pm every Tuesday, are intended to provide an organized approach to and oversight of programmatic compliance with DDAP Regulations. The weekly meetings, participants, and agenda items will be documented and stored in a 3-ring binder, which will be located in the office of the Chief Clinical Officer. |