INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 30-December 1, 2021 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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704.11(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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #5 and #8's employee records.Employee #5 was hired as a counselor on January 2, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee #5's record only documented 4 hours of annual training for the training year reviewed.Employee #8 was hired as a counselor on December 22, 2015 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee #8's record only documented 4 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both counselors are no longer employed by Pocono Mountain Recovery Center. A policy will be put in place that provides guidelines to prevent counselors from falling behind on their professional obligations. The counselors will also be provided with a contract that outlines their professional responsibilities. Every Quarter the Clinical Director will meet with the counselors and review the hours of continuing education they have completed. By the end of quarter 2 if the Clinical Director notes the counselor is not keeping up with their required hours they may be subject to progressive discipline.
The Clinical Director will provide a report to the CEO, Director of Quality and Human Resource Manager every Quarter about the counselor's progress towards continuing education goals. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Paper towels have been installed in all patient rooms.
The Facility Director and housekeeping
monitor the paper towel supply in patients rooms daily. A supply is always available to clients if they run out.
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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 a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. Room #21's hot water was recorded at 130 degrees.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PO59:
A device was installed to assure cold water would be mixed with the bathroom sink's hot water to assure the hot water temperature does not exceed 120 degrees F.
The Facility Director or designee will take the water temperature in 5 client rooms monthly.
A log of the water temperature checks will be available in the electronic system TELS, that Facility Management uses to document all maintenance tasks. client's use. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. A portable space heater was in the sunroom. The finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A contracted vendor that provides Yoga instruction had brought the heater in that day. Facility's Director and staff were unaware of the practice. The contractor was made aware that this is unacceptable and that no portable heaters are to be used in the facility. Facility Maintenance staff will check the Yoga room on days when Yoga takes place to assure that a portable heater is not present. A log will be kept of the checks and the findings. They will be reported to the Director of Quality weekly. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. The housekeeping room did not have a fire extinguisher.The finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Due to painting the fire extinguisher had been removed. It was immediately replaced upon the finding. It is checked monthly as evidenced by the required tag with signatures. This is part of monthly facility walkthrough conducted by leadership staff as well. Any missing fire extinguishers are to be reported to the Director of Quality immediately. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in the project, including the reason for the termination in four out of four applicable records.Client #4 was admitted on September 12, 2021 and was discharged on October 8, 2021. Client #8 was admitted on September 28, 2021 and was discharged on October 8, 2021.Client #20 was admitted on October 5, 2021 and was discharged on October 15, 2021.Client #25 was admitted on November 20, 2021 and was discharged on December 1, 2021The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy for Involuntary Discharge was not consistently followed. A form letter was drafted containing all the required elements. The form letter was also added to the electronic medical record as a form so it is accessible to all staff that may need to access it.
All staff that may need to complete an Involuntary Discharge will be educated about the requirement to provide the letter and that it is completely and correctly filled out.
The Clinical Director will monitor the documentation to assure that all elements of the policy have been followed.
The monitoring will be turned into the Director of Quality monthly for review for 6 months. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document that the client shall have an opportunity for reconsideration of a decision to terminate treatment in four out of four applicable records.Client #4 was admitted on September 12, 2021 and was discharged on October 8, 2021. Client #8 was admitted on September 28, 2021 and was discharged on October 8, 2021.Client #20 was admitted on October 5, 2021 and was discharged on October 15, 2021.Client #25 was admitted on November 20, 2021 and was discharged on December 1, 2021The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy for Involuntary Discharge was not consistently followed. A form letter was drafted containing all the required elements. The form letter was also added to the electronic medical record as a form so it is accessible to all staff that may need to access it.
All staff that may need to complete an Involuntary Discharge will be educated about the requirement to provide the letter and that it is completely and correctly filled out.
The Clinical Director will monitor the documentation to assure that all elements of the policy have been followed.
The monitoring will be turned into the Director of Quality monthly for review for 6 months |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The sign for the Out Patient building had been removed when the glass in the door was cleaned. The signage was replaced. It will be added to the monthly check list in TELS (our electronic maintenance system). This item will come up every month for inspection by Facilities Maintenance. If the sign is missing the Director of quality is to be immediately notified. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The sign for the Out Patient building had been removed when the glass in the door was cleaned. The signage was replaced. It will be added to the monthly check list in TELS (our electronic maintenance system). This item will come up every month for inspection by Facilities Maintenance. If the sign is missing the Director of quality is to be immediately notified. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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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 an aftercare plan in three out of four records reviewed. Client #12 was admitted on October 8, 2021 and was discharged on October 26, 2021.Client #13 was admitted on October 8, 2021 and was discharged on October 22, 2021.Client #14 was admitted on November 11, 2021 and was discharged on November 21, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will reeducate all clinical staff on the requirements for completion of aftercare plans. The Clinical Director will monitor 10 client records monthly for 6 months. The Clinical Director will look at the aftercare plan for compliance. The monitoring will be sent to the Director of Quality monthly for review |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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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 a discharge summary in two out of four records reviewed. Client #12 was admitted on October 8, 2021 and was discharged on October 26, 2021.Client #14 was admitted on November 11, 2021 and was discharged on November 21, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will reeducate all clinical staff on the requirements for completion of discharge summaries. The Clinical Director will monitor 10 discharged client records monthly for 6 months. The Clinical Director will look at the discharge summary for compliance. The monitoring will be sent to the Director of Quality monthly for review. |
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 three out of three applicable discharge records reviewed.Client #23 was admitted on September 15, 2021 and was discharged on September 24, 2021. Client #26 was admitted on June 28, 2021 and was discharged on July 19, 2021.Client #27 was admitted on August 23, 20021 and was discharged on September 9, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The process for follow up information will be redesigned. Counselors will be assigned the task of performing the first follow up call when a client has been discharged. The counselor will document in the client's record that the call was made, if contact was made and how the client is doing at the time of the call. The record will also note if a message was left for clients who do not answer. This will be monitored by the Clinical Director monthly for 6 months and the results given to the Director of Quality for review. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The sign for the Out Patient building had been removed when the glass in the door was cleaned. The signage was replaced. It will be added to the monthly check list in TELS (our electronic maintenance system). This item will come up every month for inspection by Facilities Maintenance. If the sign is missing the Director of quality is to be immediately notified. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The sign for the Out Patient building had been removed when the glass in the door was cleaned. The signage was replaced. It will be added to the monthly check list in TELS (our electronic maintenance system). This item will come up every month for inspection by Facilities Maintenance. If the sign is missing the Director of quality is to be immediately notified. |