INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10-11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Oil Region Recovery, Inc 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
The facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor for the first six months of employment in that position in one of one personnel record.
Four personnel records were reviewed on April 10-11, 2019. One personnel record reviewed was that of the clinical supervisor. The facility failed to document monthly supervision meetings in personnel record # 2.
Employee # 2 was hired for the position of clinical supervisor on May 29, 2018. There was no documentation of monthly supervision meetings provided.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director will hold and document monthly meetings with the clinical supervisor. The documentation will be placed in the clinic supervisors personnel file monthly. |
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 provide at least one staff person, trained in CPR and first aid, onsite during the project's hours of operation.
CPR and first aid cards were reviewed on April 10-11, 2019. Staff schedules were reviewed for the period of March 8 to April 9, 2019. The facility did not have a person onsite certified in CPR for ten overnight shifts during that time.
There was no CPR certification provided for a staff member working the overnight shift. The staff person was on an overnight shift alone on March 9, 12, 13, 20, 21 22, 23, 24, April 1 and 2,2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director reviewed personnel files and all new hires, and scheduled CPR training for all personnel needing updated or qualified in CPR. The CPR Trainer is scheduled to make regular follow ups to insure all staff members stay current with CPR. Clinical Supervisor, Program Assistant Supervisor, and Project Director will review CPR certifications to insure all personnel attend training at the appropriate times. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to maintain the confidential identity of the clients residing in the facility.
A physical plant walk through was completed on April 11, 2019. Bedrooms along the street side of the facility had curtains that could been seen through. Individuals walking on the street outside the facility would be able to see into the client rooms.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director installed new blinds and new curtains, which should block the public view from the street. The new curtains and blinds should prevent this problem in the future. If the blinds or curtains become damaged the facility will replace them. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to document written acknowledgement that clients were informed of their rights which included that the reasons for removing sections shall be documented in the record, in seven of seven client records.
Seven client records were reviewed on April 10-11, 2019. All required written acknowledgement that the client was informed of their rights.
Client records # 1, 2, 3, 4, 5, 6 and 7 were missing written acknowledgement that the client
was informed that the reasons for removing sections would be documented in the record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor has revised the client rights and acknowledgment record to include the clients have the right to inspect their record after unfavorable information is removed to protect the client. Clinic Supervisor will conduct a staffing to instruct all employees that complete admissions how to utilize the new document. Clinical Supervisor will review client charts weekly to ensure the client rights and acknowledgment is being utilized. This document has been revised as of 04/21/2019. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to develop policies and procedures that included the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
The policy and procedure manual was reviewed on April 10-11, 2019. There were no policies documented for the review and identification of causes.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will be notified of an unusual incident by the supervisor or the on-call supervisor. Project Director will review the incident and determine the cause of the incident and take any course of action to prevent the action from taking place in the future. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to develop policies and procedures that included the implementation of a timely and appropriate corrective action plan, when indicated.
The policy and procedure manual was reviewed on April 10-11, 2019. There were no policies documented for the implementation of a timely and appropriate corrective action plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.34 Revision 100
Project Director will be notified of an unusual incident by the supervisor or the on-call supervisor. Project Director will review the incident and determine the cause of the incident and take any course of action to prevent the action from taking place in the future.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to develop policies and procedures that included the ongoing monitoring of the corrective action plan.
The policy and procedure manual was reviewed on April 10-11, 2019. There were no policies documented for the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.34 Revision 101
The Project Director or the appropriate supervisor will develop a corrective action plan in timely manner for unusual incident that require corrective action. The Project Director will monitor all corrective action plans and ensure they are being implemented properly.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the presence of ambulance personnel.
The unusual incident reports were reviewed on April 10-11, 2019. An ambulance was present at the facility on two separate occasions, September 19, 2018 and December 18, 2018. There was no documentation provided that the unusual incidents had been filed with the Department as of April 11, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.34 Revision 102
In an event that an unusual incident report will be completed involving emergency personnel to include fire, police, or ambulance personnel; or to include an assault in any manner; or natural disaster causing the facility to close for 1 day or more; or death or serious injury will be reported to the Department within 3 business days by the Project Director. The Project Director and the Clinical Supervisor will review the event and make any possible changes to avoid the same situation in the future.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The facility failed to develop an individual treatment and rehabilitation plan that included long term goals in five of seven client records.
Seven client records were reviewed on April 10-11, 2019. All client records required documentation of a treatment and rehabilitation plan. Client records # 1, 2, 3, 6 and 7 did not document long term goals on the individual treatment and rehabilitation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor revised treatment plan to include long term and short term goals, as well as held a staffing with counselors to instruct them to develop long term and short term goals for clients during treatment period. Counselors will be educated on developing long term and short term goals as well as individual treatment plans. Clinic Supervisor will review charts on a weekly basis to ensure the revised treatment plans are being used and long term and short term goals are being developed. |
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
The facility failed to develop an individual treatment and rehabilitation plan that included the type and frequency of treatment services in seven of seven client records.
Seven client records were reviewed on April 10-11, 2019. All client records required documentation of a treatment and rehabilitation plan. Client records # 1, 2, 3, 4, 5, 6 and 7 did not document the type and frequency of services on the individual treatment and rehabilitation. The treatment plans listed 1x on the plan. The plan did not indicate whether this was one time a week, month, etc. The type of service was not documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will conduct a staff training with counselors to affectively note with daily, weekly or monthly when they list sessions to be more clear when marking the frequency of contact with the client. Clinical Supervisor will review client charts on a weekly basis to ensure the counselors are properly noting their frequency of sessions. |
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
The facility failed to develop an individual treatment and rehabilitation plan that included support services in six of seven client records.
Seven client records were reviewed on April 10-11, 2019. All client records required documentation of a treatment and rehabilitation plan. Client records # 1, 2, 3, 4, 6 and 7 did not document support services on the individual treatment and rehabilitation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will conduct a staff training to ensure the counselors are affectively making adequate treatment plans with the proper support services. Treatment plan will be modified to include three types of support services available to the clients. Counselors will review all support services with the client to insure the best possible options for the client. Clinical Supervisor will review client charts to ensure counselors are notifying clients of proper support services. |
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
The facility failed to document follow up information in four of four client records.
Seven client records were reviewed on April 10-11, 2019. Four were reviewed as closed records and required follow up documentation. Per facility policy, follow up is to be completed within seven days of discharge. Client records # 4, 5, 6 and 7 were missing follow up documentation.
Client # 4 was due to have a follow up completed by March 21, 2019. No follow up was documented.
Client # 5 was due to have a follow up completed by February 16, 2019. No follow up was documented.
Client # 6 was due to have a follow up completed by January 3, 2019. No follow up was documented.
Client # 7 was due to have a follow up completed by December 25, 2018. No follow up was documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director and Clinical Supervisor have developed a follow up program to operate on a weekly and monthly basis to insure all follow contacts are being made correctly and timely. A binder will be kept in a confidential location organized in a monthly manner to insure the follow up contact will be made at the appropriate time by the Project Director |