INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on December 4 & 5, 2023, 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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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 thirteen personnel records, the facility failed to ensure that four counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #10 was hired on April 8, 2023 as a counselor assistant and is current in that position. Employee #10 has a high school diploma and may counsel clients only under direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #10 did not receive formal case review during supervisions occurring on April 25, May 2, 9, 16, 23, 30, June 6, 13, 27, July 11, 18, 25, August 15, 29, September 19, October 17, 24, and November 7, 2023. Employee #10 did not have documented direct observations from May through October 2023. 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 #11 was hired on April 6, 2023 as a counselor assistant and is current in that position. Employee # 11 has a high school diploma and may counsel clients only direct observation of a trained counselor clinical supervisor for the first 3 months of employment and close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #11 did not receive formal case review during supervisions occurring on April 12, 19, 26, May 3, 31, June 21, 28, July 12, 26, August 2, 16, 23, 30, September 20, October 18, 25 and November 8, 2023. Employee #11 did not have documented direct observations from April through November 2023. 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 #12 was hired on June 13, 2022 as a counselor assistant and is current in that position. Employee # 12 has a high school diploma and may counsel clients only direct observation of a trained counselor clinical supervisor for the first 3 months of employment and close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #12 did not receive formal case review during supervisions occurring on March 1, 8, 15, 22, 29, April 5, 27, May 4, 11, June 1, 22, 29, July 13, 27, and August 17, 24, 31, 2023. Employee #12 did not have documented one hour direct observations from August through September 2023. 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 #13 was hired on September 28, 2023 as a counselor assistant and is current in that position. Employee # 13 has a high school diploma and may counsel clients only direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #13 did not receive formal case review during supervisions occurring on October 4, 11, 18, and 25, 2023. Employee #12 did not have documented direct observations from date of hire to the licensing 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 " . Based on a review of the supervision notes there is no documented formal case review or direct observation for the first six months of employment.
This is a repeat citation from the January 5, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CA Supervision Note Form is being revised to ensure that the CA is receiving the correct supervision and to improve the documentation process of entering all required elements of the supervisory session through the addition of prompts for each element, including but not limited to:
1) hire date
2) credentials
3) whether the supervision is direct observation or close supervision based on DDAP regulations
4) start date and projected end date of direct observation and/or close supervision
The Director of Clinical Services or designee will ensure the completion of the direct observation and close supervision as required for each particular CA via:
1) sitting in on a random sample of supervised activities
2) weekly review of documentation of services provided with signatures of both the CA and the counselor
The CA will not be promoted to counselor until all required direct observation and/or close supervision occurs and is confirmed by the Director of Clinical Services or the Manager of Clinical Services.
The expectation completion date of implementation of the new form and process will be 01/08/2024. |
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 thirteen personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that one employee received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on May 11, 2022 and was current in that position. Employee #5 was due to have the communicable disease trainings no later than May 11, 2023. There was no documentation in the personnel record of the completion of the HIV/AIDS training and the TB/STD training 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 has developed a live training tracker for the Clinical Department (including the CAs) that all clinical staff will update as trainings are completed.
The Director of Clinical Services will monitor the tracker and address any outstanding trainings with staff prior to the actual training deadline to ensure completion of the training.
The Director of Q&PI will request all staff training certificates on a monthly basis and will address any missing trainings with the Clinical Director and Clinical Manager to ensure completion of the training.
The expected completion date of the implementation of this process will be 01/15/2024. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of the medication administration records, the facility failed to document the administration, or the reason a medication was not administered.
Client #22 was prescribed Seroquel to be give one time daily. There was no documentation of the medication being administered or the reason not administered on October 27, 2023.
This is a repeat citation from the January 5, 2023 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The 7PM-7AM nursing staff will review the MARs for missed signatures and fill out the Missed MARs form in the front of each MARs book and will review that medication refusals are noted on the medication refusal form. They will place a flag on any pages that have missing initials and sign off on the Missed MARs Checklist form located in the front of each MARs book and then place that in the mailbox of the Manager of Nursing Services. The Manager of Nursing Services will then follow up with nursing staff as appropriate regarding any identified issues.
The Director of Nursing Services and the Manager of Nursing Services were aware of this deficiency during the inspection and acted immediately. As a result, the completion date of this plan of correction occurred on 12/10/2023. |
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 the client records, the facility failed to provide counseling to a client on a regular and scheduled basis to include individual counseling at least twice weekly in three out of seven records reviewed.
Client #12 was admitted on February 14, 2023 and discharged on April 6, 2023. The weeks of March 7, 24 and April 5, 2023, the client only received one individual counseling session.
Client #16 was admitted on November 1, 2023 and was still active at the time of the inspection. There was no documented individual counseling the week of November 12, 2023 and only one individual counseling session the weeks of November 19 and November 26, 2023.
Client #17 was admitted on October 9, 2023 and was still active at the time of the inspection. There was no individual counseling the weeks of October 15, 22, 29 and November 12, 2023. There was only one individual counseling session the weeks of November 6, 19, and 26, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services will be responsible for ensuring that the following actions steps occur:
The Director of Clinical Services or designee will provide education to the clinical staff on providing individual counseling to each client at a minimum of twice per week.
The Director of Clinical Services or designee will randomly select an individual counseling session to observe on a weekly basis.
The Manager of Clinical Services will be conducting a structured documentation review in supervisions to ensure that all individual counseling sessions are completed at least twice per week and that all services are documented on time and in accordance with the client's treatment plan. Findings will be reported to the Director of Clinical Services.
The Director of Q&PI will monitor the status of the POC and will schedule quarterly leadership meetings to review the progress and/or any issues that arise.
The expected completion date will be 01/15/2024. |
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 client records, the facility failed to provide a complete client record, which is to include follow up information in one out of one applicable discharged record reviewed.
Client #15 was admitted on April 7, 2023 and discharged on May 7, 2023. There was no documentation that a follow up occurred per the facility ' s policy and procedures manual of within one week of discharge.
This is a repeat citation from the January 5, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The follow-up phone calls are made by the access center. The Admissions Supervisor or designee will check for completion of these calls on a weekly basis.
1) If the access center completed the call, this information will be documented in the client's EHR by the Admissions Supervisor or designee.
2) If the call was not completed by the access center, the Admissions Supervisor or designee will make the call to the client and will document that attempt and outcome in the revised Aftercare Follow-Up Note in the EHR.
In addition to Acadia's quarterly chart audits, the Clinical Director or designee will conduct weekly chart audits of discharged clients to ensure completion of the follow-up calls.
The Director of Q&PI and the Clinical Director will jointly monitor that the plan of correction is being followed.
The expected completion date of the revised form and implementation of the process will be 01/08/2024. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of patient records, the facility failed to verify the individual had reached 18 years of age prior to administration of an agent in two out three applicable records reviewed.
Patient #4 was admitted on November 15, 2023 and discharged on November 21, 2023. There was no documentation that the facility obtained verification of the patient ' s age prior to administering an agent.
Patient# 7 was admitted on July 27, 2023 and discharged on August 3, 2023. There was no documentation that the facility obtained verification of the patient ' s age prior to administering an agent.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Q&PI will revise the existing policy to reflect the various forms of acceptable proof of ID(including photo and age).Facility staff and the access center will be educated on these various forms of IDs, so the client has them upon admission. Staff will document a note regarding all requests for ID, attempts to assist the client, and the outcome of the attempts.
The expected completion date of the revised policy and implementation of the revised process will be 01/19/2024. |
715.24(4)(ii) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(4) Minimum requirements for short-term narcotic detoxification treatment are as follows:
(ii) The narcotic treatment program shall perform an initial drug screening test or analysis.
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Observations
Based on a review of patient records, the facility failed to perform an initial drug screening test or analysis in one out of three patient records reviewed.
Patient # 3 was admitted on December 2, 2023 and was still active at the time of the inspection. There was no documentation that a drug screen was conducted on the patient during the admission process.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Nursing Services and/or the Manager of Nursing Services ensures that the nursing staff are compliant with the following regarding UDS testing.
Urine drug screen (UDS) testing will be performed by the facility upon admission and as needed.
1) Patients will be educated regarding the Urine Drug Screen process and prior to Urine Drug Screen completion.
2) Consent is signed on admission for testing.
3) Materials:
3a) Urine specimen container
3b) Gloves
4) Patient is given a specimen cup.
5) Patient then goes to a designated restroom; accompanied by a staff member who will observe the drug test in order to ensure that an appropriate urine specimen is obtained as well as ensure it is unadulterated.
6) Staff member will bring urine specimen directly to the appropriate area for reading and documentation of the results
7) Staff may request a Urine Drug Screen on a patient under the following circumstances:
7a) At any time a patient leaves the facility then returns
7b) Patient's behavior and/or appearance warrants suspicion of drug use
7c) Report of suspected drug use by other patients and/or staff
7d) Random UDS
The expected completed date is 12/05/2023. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed.
Client #5 was admitted on November 20, 2023 and discharged on November 27, 2023. There was no documentation that a follow up occurred in the client record.
Client #6 was admitted on October 16, 2023 and discharged on November 10, 2023. There was no documentation that a follow up occurred in the client record.
This is a repeat citation from the November 2, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow-up phone calls are made by the access center. The Admissions Supervisor or designee will check for completion of these calls on a weekly basis.
1) If the access center completed the call, this information will be documented in the client's EHR by the Admissions Supervisor or designee.
2) If the call was not completed by the access center, the Admissions Supervisor or designee will make the call to the client and will document that attempt and outcome in the revised Aftercare Follow-Up Note in the EHR.
In addition to Acadia's quarterly chart audits, the Clinical Director or designee will conduct weekly chart audits of discharged clients to ensure completion of the follow-up calls.
The Director of Q&PI and the Clinical Director will jointly monitor that the plan of correction is being followed.
The expected completion date of the revised form and implementation of the process will be 01/08/2024. |
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
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in one out of three applicable records reviewed
Client #18 was transferred from the partial hospitalization level of care to the outpatient level of care on November 10, 2023 and was still active at the time of the inspection. Client #18 ' s last treatment plan update occurred August 2, 2023 in the previous level of care, there was no documentation that another update was completed prior to the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director or designee will ensure that treatment plans in the outpatient department are updated upon admission to PHP, transfer to IOP, and any other time as required for updates or when clinically indicated. This will be reviewed through Acadia's quarterly chart audit process and through intradepartmental documentation reviews.
The expected date of completion will be 01/08/2024.
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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 provide a complete client record, which is to include follow up information in five out of six applicable discharged record reviewed.
Client #12 was admitted on April 6, 2023 and discharged on April 14, 2023. There was no documentation that a follow up occurred per the facility ' s policy and procedures manual of within one week of discharge.
Client #13 was admitted on April 10, 2023 and discharged on May 2, 2023. There was no documentation that a follow up occurred per the facility ' s policy and procedures manual of within one week of discharge.
Client #14 was admitted on June 8, 2023 and discharged on June 29, 2023. There was no documentation that a follow up occurred per the facility ' s policy and procedures manual of within one week of discharge.
Client #19 was admitted on December 19, 2022 and discharged on January 13, 2023. There was no documentation that a follow up occurred per the facility ' s policy and procedures manual of within one week of discharge.
Client #20 was admitted on January 21, 2023 and was discharged on February 2, 2023. There was no documentation that a follow up occurred per the facility ' s policy and procedures manual of within one week of discharge.
This is a repeat citation from the December 1, 20212 and January 5, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow-up phone calls are made by the access center. The Admissions Supervisor or designee will check for completion of these calls on a weekly basis.
1) If the access center completed the call, this information will be documented in the client's EHR by the Admissions Supervisor or designee.
2) If the call was not completed by the access center, the Admissions Supervisor or designee will make the call to the client and will document that attempt and outcome in the revised Aftercare Follow-Up Note in the EHR.
In addition to Acadia's quarterly chart audits, the Clinical Director or designee will conduct weekly chart audits of discharged clients to ensure completion of the follow-up calls.
The Director of Q&PI and the Clinical Director will jointly monitor that the plan of correction is being followed.
The expected completion date of the revised form and implementation of the process will be 01/08/2024. |
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 December 21, 2021 and January 5, 2023 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the December 4 & 5, 2023 licensing inspection.
A plan of correction for completing and documenting follow-up information for the partial records was submitted and approved by the Department for the January 5, 2023 annual licensing inspection. Completing and documenting follow-up information was again found to be a deficiency in the December 4 & 5, 2023 licensing inspection.
A plan of correction for completing and documenting follow-up information for the inpatient records was submitted and approved by the Department for the January 5, 2023 annual licensing inspection. Completing and documenting follow-up information was again found to be a deficiency in the December 4 & 5, 2023 licensing inspection.
A plan of correction for completing and documenting medication administration was submitted and approved by the Department of the January 5, 2023 annual licensing inspection. Completing and documenting medication administration was again found to be a deficiency in the December 4 & 5, 2023 licensing inspection.
A plan of correction for counselor assistant supervision was submitted and approved by the Department for the January 5, 2023 annual licensing inspection. Counselor assistant supervision was again found to be a deficiency in the December 4 & 5, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Q&PI will schedule quarterly facility management meetings to review the status of all items in the Statement of Deficiencies and compliance with the POCs. All attendees will sign a meeting attendance sheet.
The Director of Q&PI will develop a tracker for all items, compliance, and notes from each quarterly meeting.
The expected completion date will be 03/11/2024. |