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 7-8, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Millerton Acquisition Sub, LLC DBA Bradford Recovery Center 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on direct observation during the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Two group sessions were being held in the dining room, which did not ensure privacy during the sessions.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Groups will no longer be held in the cafeteria. Groups will be held in group rooms, in counselor offices and/or on the stage which can be closed off.
The facility director will ensure compliance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical site inspection, the facility failed to provide hot water in the trailer bathroom which is used for counseling sessions.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The hot water heater in the trailer will be replaced by January 3, 2023.
The operations director will ensure it is installed. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from January 2022 through November 2022, the facility failed to include all the required information. The exit route used was not documented in March, May, June, July, August and October 2022. And if the fire alarm was operative was not documented in July, August, September, October and November 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Regional quality director reviewed proper completion of the fire drill logs with the plant manager. Plant manager verbalizes understanding the importance of documenting the exit route and whether or not the fire alarm was operable.
Fire drills for the first four months of 2023 will be reviewed by the RVP/Quality Director for proper completion. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document a psychosocial evaluation in five out of six records reviewed.
Client #1 was admitted on September 15, 2022 and was still active at the time of the inspection.
Client #2 was admitted on August 28, 2022 and was still active at the time of the inspection.
Client #3 was admitted on September 23, 2022 and was still active at the time of the inspection.
Client #4 was admitted on July 23, 2022 and discharged on September 9, 2022.
Client #6 was admitted on July 21, 2022 and discharged on September 15, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The psychosocial evaluation will be completed on clients #1, 2 and 3 by December 23, 2022 if they are still in treatment
Clinical staff will be educated on the importance of completing biopsychosocial assessments within the first three days of admission to the partial hospital program.
If a client is a transfer from the residential program to the partial hospital program, the biopsychosocial will be reviewed with the client upon change in level of care to see if anything has changed.
The clinical director will review 10 partial hospitalization charts per month for the next four months to ensure timely completion of biopsychosocial assessments. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of partial hospitalization client records, the facility failed to document type and frequency of treatment service on client's individual treatment plans in three out of five records reviewed.
Client #2 was admitted on August 28, 2022 and was still active at the time of the inspection. The treatment plan was dated November 8, 2022.
Client #4 was admitted on July 23, 2022 and discharged on September 9, 2022. The treatment plan was dated July 26, 2022.
Client #6 was admitted on July 21, 2022 and discharged on September 15, 2022. The treatment plan was dated July 28, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The individual treatment plan will be completed in it's entirety on client #2 by December 28, 2022, if he/she is still in treatment. This will include adding the type and frequency of treatment to the treatment plan.
Clinical staff will be educated by the clinical director on the importance of adding the type and frequency of treatment service on an individual's treatment plan.
The clinical director will review 10 partial hospitalization charts per month for the next four months to ensure treatment plans are being completed correctly which includes the type and frequency of treatment services. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
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Observations
Based on the review of partial hospitalization client records, the facility failed to document proposed support services on client's individual treatment plans in three out of five records reviewed.
Client #2 was admitted on August 28, 2022 and was still active at the time of the inspection. The treatment plan was dated November 8, 2022.
Client #4 was admitted on July 23, 2022 and discharged on September 9, 2022. The treatment plan was dated July 26, 2022.
Client #6 was admitted on July 21, 2022 and discharged on September 15, 2022. The treatment plan was dated July 28, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The individual treatment plan will be completed in its entirety on client #2 by December 28, 2022, if he/she is still in treatment. This will include documenting support services on the treatment plan.
Clinical staff will be educated by the clinical director on the importance of documenting support services on an individual's treatment plan.
The clinical director will review 10 charts per month for the next four months to ensure treatment plans are being completed correctly and proposed support services are added. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to update treatment plans at least every 30 days in four out of four applicable records, as there were no updates documented in the clients records.
Client #1 was admitted on September 15, 2022 and was still active at the time of the inspection. A treatment plan was dated October 11, 2022.
Client #2 was admitted on August 28, 2022 and was still active at the time of the inspection. A treatment plan was completed on November 8, 2022.
Client #4 was admitted on July 23, 2022 and discharged on September 9, 2022. A treatment plan was dated July 26, 2022.
Client #6 was admitted on July 21, 2022 and discharged on September 15, 2022. A treatment plan was dated July 28, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The treatment plan update will be completed on clients #1 and #2 by December 28, 2022, if they are still in treatment.
Clinical staff will be educated by the clinical director on the importance of/proper completion of treatment plan updates in the PHP LOC a minimum of every 30 days.
The clinical director will review 10 PHP charts per month for the next four months to ensure treatment plan updates are being completed timely and properly. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of partial hospitalization client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in one out of two applicable records reviewed.
Client #1 was admitted on September 15, 2022 and was still active at the time of the inspection. A treatment plan dated October 11, 2022 indicated individual treatment twice a week. The weeks of October 16-22 and 23-29, 2022, the client received one individual session each week.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #1 will receive treatment according to his/her treatment plan if he/she is still in treatment. This will include individual treatment twice per week.
The clinical director will educate clinical staff on the importance of following the treatment plan as the map for care.
The clinical director will review 10 charts for the next four months to ensure clinical staff are conducting treatment according to the treatment care plan and following that plan for services. |
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 the review of partial hospitalization client records, the facility failed to provide individual counseling at least twice weekly in five out of six records reviewed.
Client #1 was admitted on September 15, 2022 and was still active at the time of the inspection. The weeks of October 16-22 and 23-29, 2022, the client received one individual session each week.
Client #2 was admitted on August 28, 2022 and was still active at the time of the inspection. The week of November 6-12, 2022, the client received zero individual sessions. The client received one individual session each week between November 13-December 3, 2022.
Client #3 was admitted on September 23, 2022 and was still active at the time of the inspection. The client received zero individual sessions the week of October 30 - November 5, 2022.The client received on individual session each week between November 13-26, 2022.
Client #4 was admitted on July 23, 2022 and discharged on September 9, 2022. During his/her admission, the client only received two individual sessions on August 1 and September 2, 2022.
Client #6 was admitted on July 21, 2022 and discharged on September 15, 2022. The client received zero individual sessions between July 31 - August 13, 2022. The client received on individual session each week between August 14 - September 10, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical staff will be educated by the clinical director on the importance of providing individual counseling at least twice weekly in the partial hospitalization level of care.
The clinical director will review 10 charts per month for the next four months to ensure partial hospitalization patients are receiving individual counseling twice weekly. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of detoxification patient records, the facility failed to complete an initial drug-screening urinalysis in one out of two applicable records reviewed.
Client #12 was admitted to the detoxification unit on August 2, 2022 and transferred to the residential program on August 6, 2022.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nursing staff will be re-educated on the importance of obtaining an initial urine drug screen at the time of admission and prior to initiating detoxification medications for opiate withdrawal management.
Education will be conducted by the DON.
The DON will review 10 detox charts for the next 4 months to ensure compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of residential client records, the facility failed to document a psychosocial evaluation in six out of six records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical staff will be educated on the importance of completing biopsychosocial assessments within the first three days of admission to residential treatment.
The clinical director will review 10 residential charts per month for the next four months to ensure timely completion of biopsychosocial assessments. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of residential client record, the facility failed to document type and frequency of treatment service on client's individual treatment plans in two out of four applicable records reviewed.
Client #15 was admitted on November 14, 2022 and was still active at the time of the inspection. The treatment plan was dated November 16, 2022.
Client #16 was admitted on November 1, 2022 and was still active at the time of the inspection. The treatment plan was dated November 8, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The individual treatment plan will be completed in its entirety on client #15 and client #16 by December 28, 2022, if they are still in treatment. This will include adding the type and frequency of treatment to the treatment plan.
Clinical staff will be educated by the clinical director on the importance of adding the type and frequency of treatment service on an individual's treatment plan.
The clinical director will review 10 residential charts per month for the next four months to ensure treatment plans are being completed correctly which includes the type and frequency of treatment services. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on the review of residential client record, the facility failed to document proposed support services on client's individual treatment plans in two out of four applicable records reviewed.
Client #15 was admitted on November 14, 2022 and was still active at the time of the inspection. The treatment plan was dated November 16, 2022.
Client #16 was admitted on November 1, 2022 and was still active at the time of the inspection. The treatment plan was dated November 8, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The individual treatment plan will be completed in its entirety on client #15 and client #16 by December 28, 2022, if they are still in treatment. This will include documenting support services on the treatment plan.
Clinical staff will be educated by the clinical director on the importance of documenting support services on an individual's treatment plan.
The clinical director will review 10 residential charts per month for the next four months to ensure treatment plans are being completed correctly and proposed support services are added. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of residential client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of four applicable records reviewed.
Client #18 was admitted on June 1, 2022 and discharged on July 28, 2022. A treatment plan dated June 2, 2022 indicated individual sessions weekly. The client received one individual session on June 13, 2022.
Client #19 was admitted on June 4, 2022 and discharged on July 18, 2022. A treatment plan dated June 6, 2022 indicated weekly individual sessions. The client did not receive any individual sessions between July 10-16, 2022.
Client #20 was admitted on July 29, 2022 and transferred to the partial hospitalization program on August 9, 2022. The treatment plan dated August 4, 2022 indicated weekly individual sessions. The client did not receive any individual sessions from July 29 - August 9, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical director will educate clinical staff on the importance of following the treatment plan as the map for care as well as the importance of conducting individual sessions according to the treatment plan.
The clinical director will review 10 residential charts for the next four months to ensure clinical staff are conducting treatment according to the treatment care plan and following that plan for services/individual sessions. |