INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2022 through January 13, 2022 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors, who have not functioned for 2 years as a supervisor in the provision of clinical services prior to hiring, completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee #2 was hired as a clinical supervisor on February 3, 2020 and did not have clinical supervision experience prior to being hired. There was no documentation of the clinical supervision core curriculum training on file at the time of the inspection.
This is a repeat citation from the January 11, 2021 through January 12, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.6 Plan of Correction: Employee #2: Clinical Supervisor will complete the DDAP core-curriculum in Clinical Supervisor training within the established training timeframe. This training will be added to the Clinical Supervisor's required training plan for the established annual timeframe, which will be monitored by the Clinical Program Director. The Clinical Supervisor will provide documentation/ certification of completion for this training, which will be placed in employee file. This must be completed by 12/31/2022. Furthermore, Pennsylvania Recovery Center, LLC (PARC) will up their Policies and Procedures to reflect this requirement in the job description for Clinical Supervisor. This correction will be made by 02/01/2022. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop a comprehensive staff development program for agency personnel, which is to include policies and procedures for the program indicating who is responsible and the time frames for completion for the following components: an assessment of staff training needs, an overall plan for addressing those needs, a mechanism to collect feedback on completed trainings, and an annual evaluation of the overall training plan.
This is a repeat citation from the January 11, 2021 through 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
704.11 (a) Plan of Correction: Clinical Program Director will develop, in collaboration with all clinical staff members, an annual training plan that must be completed within the annual training timeframe. The training plan must include at least 25 hours of training and will be agreed upon, signed off on by both the Clinical Program Director and each clinical staff member respective of their individualized plan. The training plan will be reviewed for progress at each weekly individual supervision between the Clinical Program Director and clinical staff members, but clinical staff members assume full responsibility to earn hourly trainings (min. of 25) within the established time-frame to uphold the plan of correction and policy and procedure outlining annual clinical staff trainings. Clinicians will provide documentation/ certification of completion for these trainings, which will be placed in employee file. This regulation will be added to PARC's Policies and Procedures as a requirement for all clinical staff, job requirements. This update will occur by 02/01/2022. Clinical staff must complete their required trainings by 12/31/2022 |
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 three of five applicable personnel records.
Employee #1 was hired as project/facility director on December 23, 2019. Both trainings were due to be completed prior to December 23, 2021. The personnel record did not include documentation that the HIV/AIDS training and the TB/STD training were completed at the time of the inspection.
Employee #3 was hired as a counselor on August 25, 2020. Both trainings were due to be completed prior to August 25, 2021. The personnel record did not include documentation that the HIV/AIDS training and the TB/STD training were completed at the time of the inspection.
Employee #5 was hired as a counselor on October 14, 2020. Both trainings were due to be completed prior to October 14, 2021. The personnel record did not include documentation that the HIV/AIDS training and the TB/STD training were completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
404.11 (c) (1): Clinical Program Director will develop, in collaboration with all clinical staff members, an annual training plan that must be completed by the end of that year's annual training timeline, which includes these training requirements. Each clinical staff member will complete 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 DDAP approved curriculum. Clinicians will provide documentation/ certification of completion for these trainings, which will be placed in employee file. Employee #1 will complete these required trainings by 03/31/2022. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed at least 12 clock hours of training, during the facility's January 1, 2021 through December 31, 2021 training year, in one of one applicable personnel records reviewed.
Employee #2 was hired as a clinical supervisor on December 2, 2019. The personnel record documented 4 hours of training for the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(e)(2) Plan of Correction: Clinical Program Director identified the annual training timeframe as 2/1/2022 to 12/30/22. Employee #2: Clinical Supervisor will complete at least 12 clock hours of training annually in areas such as: (i) Supervision and evaluation. (ii) Counseling techniques. (iii) Substance abuse trends and treatment methodologies in the field of addiction. (iv) Confidentiality. (v) Codependency/Adult Children of Alcoholics (ACOA) issues. (vi) Ethics. (vii) Interaction of addiction and mental illness. (viii) Cultural awareness. (ix) Sexual harassment. (x) Developmental psychology. (xi) Relapse prevention. (xii) Disease of addiction. (xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous. These trainings will be added to the Clinical Supervisor's required training plan for the established annual timeframe, which will be monitored weekly by the Clinical Program Director. The Clinical Supervisor will provide documentation/ certification of completion for these trainings, which will be placed in employee file. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training, during the facility's January 1, 2021 through December 31, 2021 training year, in three of four applicable personnel records reviewed.
Employee #3 was hired as a counselor on August 25, 2020. The personnel record documented 3.75 hours of training during the reviewed training year.
Employee #5 was hired as a counselor on October 14, 2020. The personnel record documented 5.5 hours of training during the reviewed training year.
Employee #6 was hired as a counselor on May 16, 2019. The personnel record documented 21 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(f)(2) Plan of Correction: Clinical Program Director identified the annual training timeframe as 2/1/2022 to 12/30/22. Clinical Program Director will develop, in collaboration with all clinical staff members, an annual training plan that must be completed within the annual training timeframe 2/1/2022-12/30/2022. The training plan must include at least 25 hours of training and will be agreed upon, signed off on by both the Clinical Program Director and each clinical staff member respective of their individualized annual training plan. Each training plan must include at least 25 clock hours of training annually in areas such as: (i) Client recordkeeping. (ii) Confidentiality. (iii) Pharmacology. (iv) Treatment planning. (v) Counseling techniques. (vi) Drug and alcohol assessment. (vii) Codependency. (viii) Adult Children of Alcoholics (ACOA) issues. (ix) Disease of addiction. (x) Aftercare planning. (xi) Principles of Alcoholics Anonymous and Narcotics Anonymous. (xii) Ethics. (xiii) Substance abuse trends. (xiv) Interaction of addiction and mental illness. (xv) Cultural awareness. (xvi) Sexual harassment. (xvii) Developmental psychology. (xviii) Relapse prevention.
Clinicians will provide documentation/ certification of completion for these trainings, which will be placed in each employee file. Clinical Program Director will monitor progress of training plans on a weekly basis during supervision.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the facility's January 2021 through December 2021 fire drill log, the facility failed to conduct an unannounced fire drill for the month of October 2021.
This is a repeat citation from the January 11, 2021 through January 12, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (1) The Director of Operations will execute monthly fire drills and document all imperative information (date, time, the amount of time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill)
in the Emergency Preparedness Binder located in the office of Director of Operations.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the facility's January 2021 through December 2021 fire drill log, the facility failed to identify, on the fire drill log, which exit route was used, the number of people in the facility at the time of the drill, and whether the fire alarm/smoke detector was operative during the drills for every drill conducted from January 2021 through December 2021.
This is a repeat citation from the January 11, 2021 through January 12, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (4) The Director of Operations will execute monthly fire drills and document all imperative information (date, time, the amount of time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill)
in the Emergency Preparedness Binder located in the office of Director of Operations. In lieu of a fire alarm, the staff member that conducts the monthly emergency/ evacuation drills will utilize an airhorn as an operative alternative.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's January 2021 through December 2021 fire drill log, the facility failed to set off the fire alarm or a smoke detector during each fire drill conducted during the reviewed period.
This is a repeat citation from the January 11, 2021 through 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
705.28 (d) (7) Due to the building being shared with other business, we do not have permission to execute fire alarms during business hours, Pennsylvania Recovery Center (PARC) will submit a request with DDAP for permission to conduct monthly fire drills w/o activating fire alarms. Smoke detectors are hard-wired with fire alarm system and PARC is not permitted by building owner/ manager to use the fire system w/o need. Building owner/ manager is legally responsible for the compliance of and maintenance of operational fire alarms/ smoke detectors. In lieu of the building's fire alarm, the staff member that conducts the monthly evacuation/ emergency drills will utilize an airhorn as an operational option. This protocol will be incorporated immediately. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This is a repeat citation from the January 11, 2021 through January 12, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.25 CEO and/ or Pennsylvania Recovery Centers, LLC business owners will consult with a certified public accountant to complete an annual financial audit and provide evidence of compliance with generally accepted accounting principles regarding drug and alcohol treatment activities. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in thirteen of fourteen client records reviewed.
Client #1 was admitted on November 18, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on November 18, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on November 8, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on November 8, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on August 6, 2021 and discharged on October 14, 2021. A release of information form to a funding source was signed and dated by the client on August 6, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on September 28, 2021 and discharged on January 7, 2022. A release of information form to a funding source was signed and dated by the client on September 28, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on September 6, 2021 and discharged on December 9, 2021. A release of information form to a funding source was signed and dated by the client on September 6, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on August 2, 2021 and discharged on November 12, 2021. A release of information form to a funding source was signed and dated by the client on August 2, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #8 was admitted on December 10, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on December 10, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #9 was admitted on November 19, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on November 19, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #10 was admitted on December 3, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on December 3, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #11 was admitted on November 15, 2021 and was discharged on December 24, 2021. A release of information form to a funding source was signed and dated by the client on November 15, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #12 was admitted on October 12, 2021 and was discharged on November 25, 2021. A release of information form to a funding source was signed and dated by the client on October 12, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #13 was admitted on November 29, 2021 and was discharged on December 28, 2021. A release of information form to a funding source was signed and dated by the client on November 29, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
Client #14 was admitted on February 17, 2021 and was discharged on March 10, 2021. A release of information form to a funding source was signed and dated by the client on February 17, 2021 that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the January 11, 2021 through January 12, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) (2) Clinical Program Director will contact 'Kipu' management of electronic medical records (EMR) system to revamp and correct the release of information template by removing all "check-boxes" that would allow the release of information outside of those permitted by 4 Pa. Code 255.5 (b). Furthermore, The Director of Operations will train support staff by 2/1/2022 on the proper implementation of the new release of information forms in the EMR. Client 1 and 3 have been discharged and the clinical records cannot be amended/ changed once clients discharge from treatment. |
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 client records, the facility failed to provide treatment plan updates within the regulatory timeframe in two of two applicable client records reviewed.
Client #9 was admitted on November 19, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on November 30, 2021 and the first update was due no later than December 30, 2021. However, the update was not completed at the time of the inspection.
Client #11 was admitted on November 15, 2021 and was discharged on December 24, 2021. The comprehensive treatment plan was completed on November 15, 2021 and the first update was due no later than December 15, 2021. However, the update was not completed prior to the client's discharge.
This is a repeat citation from the January 11, 2021 through January 12, 2021 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
709.82(b) Clinical Program Director will conduct weekly chart audits and of the electronic medical record (EMR) to ensure that all clients in the clinical program have their respective Treatment and/ or Rehabilitation Plans reviewed and updated every 30 days. Client #9 has since been discharged and the client record cannot be amended/ changed once a client discharges from treatment. |
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 a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #11 was admitted on November 15, 2021 and was discharged on December 24, 2021.
Client #12 was admitted on October 12, 2021 and was discharged on November 25, 2021.
Client #13 was admitted on November 29, 2021 and was discharged on December 28, 2021.
This is a repeat citation from the January 11, 2021 through January 12, 2021 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
709.83(a)(11) Clinical Program Director will conduct chart audits of the electronic medical record (EMR) for discharged clients at 30, 60, 90, and 120 days after discharge to ensure that the alumni coordinator is contacting/ attempting to contact discharged clients for follow-up/ outreach. Alumni coordinator will document the attempts and outcomes in the respective client record. |
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 provide treatment plan updates within the regulatory timeframe in two of three applicable client records reviewed.
Client #5 was admitted September 28, 2021 and was discharged on January 7, 2022. The comprehensive treatment plan was completed on October 7, 2021 and the first update was due no later than December 7, 2021. However, the update was completed on January 7, 2022.
Client #7 was admitted on August 2, 2021 and was discharged on November 12, 2021. A treatment plan update was completed on September 7, 2021 and the next update was due no later than November 7, 2021. However, the update was not completed prior to the client's discharge.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
709.92(b) Clinical Program Director will conduct weekly chart audits and of the electronic medical record (EMR) to ensure that all clients in the clinical program have their respective Treatment and/ or Rehabilitation Plans reviewed and updated every 60 days. |
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 a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #4 was admitted on August 6, 2021 and was discharged on October 14, 2021.
Client #6 was admitted on September 6, 2021 and was discharged on December 9, 2021.
Client #7 was admitted on August 2, 2021 and was discharged on November 12, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(11) Clinical Program Director will conduct chart audits of the electronic medical record (EMR) for discharged clients at 30, 60, 90, and 120 days after discharge to ensure that the alumni coordinator is contacting/ attempting to contact discharged clients for follow-up/ outreach. Alumni coordinator will document the attempts and outcomes in the respective client record. |