INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Wellness Recovery, 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to document that the project director and facility director met the qualifications for the position.
An off-site inspection was conducted on May 15, 2020. Staff qualifications were requested including resumes and transcripts. Both the Project Director, Staff #1 and the Facility Director, Staff #2, did not meet the educational and/or experiential qualifications for their position.
Per the Staffing Requirements Facility Summary Report, Staff #1 was hired as the Project Director on January 1, 2019. The transcripts for Staff #1 were not provided. Staff #1 had at least two years of experience in program planning and direct service, but did not have any experience documented for the supervision of others.
Per the Staffing Requirements Facility Summary Report, Staff #2 was promoted to the Facility Director on November 1, 2019. Staff #2 meets the educational requirements for the position. Staff #2 has at least two years of experience in direct service and supervision of others; however, does not have documentation of program planning.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The qualifications for both the facility director and project director have been met and the documentation has been included in the employee file.
Staff member 1 sealed transcript verifying BS degree in Psychology in on file. Resume, also on file, verifies 3 years of supervision of others experience. DDAP evaluator has been provided with documentation to support the standard being met.
Staff member 2 - curriculum vita now reflects program planning experience from previous employers.
CAP action: A postion check sheet has been developed that specifically aligns with DDAP standards. The Project Director and Facility Director will co-sign all check sheets for all employees before first day of employment. The check sheet includes verification of work experience. For the position of project director the form is cosigned by the owners of the facility and medical director. For faculty director the form is cosigned by project director and medical director.
WR is now in compliance with this standard and effective date for new verification form was June 1, 2020.
Persons Responsible: Project Director, Facility Director Medical Director |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to document CPR certification for at least one staff per shift.
An off-site inspection was conducted on May 15, 2020. Staff schedules and CPR certifications were requested. The facility operates a 24 hour detox/rehab program. One counselor assistant (aide) that provides overnight coverage had an expired CPR card. The CPR card for only one of the nurses was provided. This left multiple shifts with no documented CPR coverage.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hard copies of current CPR certification verification is now included in each employee file.
CAP action:
1. By policy, all employees must maintain current CPR certification.
2. New employees without CPR certification will be trained and certified during orientation.
3. WR will maintain one certified American Heart Association CPR Instructor on staff to immediately certify new employees and renew current employees on an annual basis
4. The Facility Director will maintain a certification expiration list to ensure compliance.
5. The Facility Director will place hard copies of the BLS certification into the employee file at the completion of training to verify compliance.
Outcome:
1. WR now has all employees in CPR compliance.
2. To meet this standard no less than 2 individuals working in the facility have CPR certification during 24/7 operations.
Completion Date: 6/1/2020
Persons Responsible: Facility Director |
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
The facility failed to document an annual financial audit associated with the project's drug and alcohol abuse services.
An off-site inspection was conducted on May 15, 2020. The annual financial audit was requested. There was no documentation of an annual financial audit for the 2018 - 2019 fiscal year and there was no exception approval.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Wellness Recovery operates on a fiscal year. We did not audit last year (20-18-2019 FY) at the advice of our CPA because there was only 45 days of revenue. WR is in its first year of operations.
CAP:
1. The project Director has contracted with an accounting firm that has a CPA and certified auditor to conduct a certified audit that will begin June 20, 2020 for the 2019-2020 fiscal year.
2. The audit will be available for review September 30, 2020.
3. The audit will be reviewed by the Project Director and Owners. Copies will be provided to all requesting agencies.
4. This process will occur annual on the last day of the fiscal year.
Date of Completion: August 1, 2020
Responsible Person: Project Director
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709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
The facility failed to document written verification of qualifying professional credentials.
An offsite inspection was conducted on May 15, 2020. Staff qualifications including resumes and transcripts were requested. The facility failed to document a transcript for Staff #1, who was hired as the project director on January 1, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WR position titles did not align with DDAP defined terminology and requirements.
CAP action: A position compliance check sheet has been developed that specifically aligns with DDAP standards. The Project Director and Facility Director will co-sign all check sheets for all employees before first day of employment. The check sheet now includes verification of work experience, credential and transcript review. For the position of project director the form is co-signed by the owners of the facility and medical director. For faculty director the form is cosigned by project director and medical director.
WR is now in compliance with this standard and effective date for new verification form was June 1, 2020.
Responsible persons: Facility Director and Project Director |