INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2021 through January 12, 2021 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
The facility failed to ensure that clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services 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 a Department approved clinical supervision training in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will develop, in collaboration with Clinical Supervisor an annual training plan that must be completed by 01/20/2022. The training plan must include at least 30 hours of training and will be agreed upon, signed off on by both the Clinical Program Director and Clinical Supervisor . The training plan will be reviewed for progress at each weekly individual supervision between the Clinical Program Director and Clinical Supervisor but the Clinical Supervisor assumes full responsibility to earn hourly trainings (min. of 30) within the established time-frame to uphold the plan of correction and policy and procedure outlining Clinical Supervisor's training. |
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 ensure that clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position in one of one applicable personnel record reviewed.
Employee # 2 was hired as a clinical supervisor on February 3, 2020. There was no documentation of clinical supervision meetings for the first six months in that position provided at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will meet with Clinical Supervisor for a minimum of 1 hour (60 minutes) each week for supervision. Clinical Program Director will document each supervisory meeting, topics of supervisor, corrective action plans, and outcomes. The Clinical Program Director will keep a 3-ring binder of the documented supervisons (hard copies) on site at facility in a locked cabinet for inspection upon request. |
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
The facility failed to provide documentation that 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 was developed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will develop, in collaboration with all clinical staff members, an annual training plan that must be completed by 01/20/2022. 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 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. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to ensure that there was a documented mechanism to collect feedback on completed trainings in two of two applicable client records.
Employee #1 was hired as the project director on December 23, 2019.
Employee #7 was hired as a counselor on May 16, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff members, upholding their agreed upon training plan, must submit documentation/ receipt of training attendance/ completion to Clinical Program Director within 5 days after they receive the official documentation/ receipt of attendance/ completed training as outlined in their respective plan. Each clinical must complete at least 25 hours of continued training/ education by 01/20/2022. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation of an individual training plan developed with input from both the employee and the supervisor for seven of seven applicable personnel records.
Employee # 1 was hired as the project director on December 23, 2019. The individual training plan was not completed as of the date of the inspection.
Employee #2 was hired as the clinical supervisor on February 3, 2020. The individual training plan was not completed as of the date of the inspection.
Employee #3 was hired as a counselor on August 25, 2020. The individual training plan was not completed as of the date of the inspection.
Employee #4 was hired as the counselor on November 10, 2020. The individual training plan was not completed as of the date of the inspection.
Employee #5 was hired as the counselor on October 14, 2020. The individual training plan was not completed as of the date of the inspection.
Employee #6 was hired as the counselor on February 7, 2020. The individual training plan was not completed as of the date of the inspection.
Employee #7 was hired as the counselor on May 16, 2019. The individual training plan was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will develop, in collaboration with all clinical staff members and Project Director an annual training plan that must be completed by 01/20/2022. 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 and Project Director 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. Clinical Program Director will meet with Project Director quarterly to assess progress of completion of agreed upon/ required annual trainings included in plan. |
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 ensure that a sufficient number of staff persons were trained in CPR and first aid during the facility's hours of operation.
The facility's hours of operation are Monday through Friday from 8:00am to 8:00pm. The facility provided documentation that only two of thirteen employees had first aid trainin and three of thirteen employees had a current CPR certification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will ensure CPR/ First Aid training is completed by all support staff and clinical staff within the next 30 days (03/11/2021). Copies of CPR/ and First Aid training certificates will be kept in respective employee's file. |
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
The facility failed to conduct unannounced fire drills for the months of March 2020, April 2020, and May 2020. This was based on the review of the January 2020 through December 2020 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Despite our facility being closed to all staff and clients during these months due to COVID-19 precautions. The Director of Operations has and will continue to execute monthly fire drills and document all imperative information in the Emergency Preparedness Binder located in the office of Director of Operations. |
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
The facility failed to document on their January 2020 through December 2020 written fire drill record whether the fire alarm or smoke detector was operative at the time of the drill for every fire drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 maintenace of operational fire alarms/ smoke detectors. |
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 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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Business owner 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. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in two of two applicable personnel records.
Employee # 1 was hired as the project director on December 23, 2019. The 2020 written staff performance evaluation was not documented complete as of the date of the inspection.
Employee #7 was hired as the counselor on May 16, 2019. The 2020 written staff performance evaluation was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will conduct and document annual written individual performance evaluations for all clinical staff. The performance evaluations will be dependent on job performance as outlined in the clinical job description, agreed to and signed by all clinical staff upon hiring. Clinical Program Director will develop a subjective rubric to assess clinicians in each domain of their job requirements in addition to completion of their respective individualized training plan. Annual performance reviews will be signed by Clinical Program Director and clinical employee and placed in respective employee file. |
709.28 (c) 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.
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Observations
The facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.
Client # 11 was admitted on March 5, 2020 and discharged on November 25, 2020. There was documentation of disclosures to a family member during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from previous renewal licensing inspection completed on January 28, 2020 through January 29, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director has instructed and trained all clinical staff on 01/21/2021 during clinical supervision to have clients sign a release of information form for each participating individual, (forms located in the electronic medical record) prior to family, support, and/or couple counseling sessions. This will be done to protect confidentiality and prevent unauthorized releases of information during or after these types of counseling sessions. Clinical Program Director will audit these types of sessions per week in addition to full chart audits of each active client. Clinical Program Director will screen for signed release of information forms in the EMR and report findings of weekly audit to clinical staff. Clinical staff failing to comply will be placed on a corrective action plan to fulfill this requirement if needed. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven of fourteen client records reviewed.
Client #1 was admitted on December 8, 2020 and was discharged on December 21, 2020. A release of information form to a funding source was signed and dated by the client on December 8, 2020 that allowed for the release of treatment plans, psychological assessments, psychiatric assessment and history, results of physical exam, medical history, biopsychological assessment laboratory results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary, and financial information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #3 was admitted on December 24, 2020 and was discharged on January 5, 2021. A release of information form to a funding source was signed and dated by the client on December 24, 2020 that allowed for the release of treatment plans, psychological assessments, psychiatric assessment and history, results of physical exam, medical history, biopsychological assessment laboratory results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary, and financial information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on December 9, 2020 and was discharged on December 24, 2020. A release of information form to a funding source was signed and dated by the client on December 9, 2020 that allowed for the release of treatment plans, psychological assessments, psychiatric assessment and history, results of physical exam, medical history, biopsychological assessment laboratory results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary, and financial information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on December 2, 2020 and was active at time of inspection. A release of information form to a funding source was signed and dated by the client on December 2, 2020 that allowed for the release of treatment plans, psychological assessments, psychiatric assessment and history, results of physical exam, medical history, biopsychological assessment laboratory results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary, and financial information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #6 was admitted on December 21, 2020 and was active at time of inspection. A release of information form to a funding source was signed and dated by the client on December 21, 2020 that allowed for the release of treatment plans, psychological assessments, psychiatric assessment and history, results of physical exam, medical history, biopsychological assessment laboratory results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary, and financial information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on December 15, 2020 and was active at time of inspection. A release of information form to a funding source was signed and dated by the client on December 21, 2020 that allowed for the release of treatment plans, psychological assessments, psychiatric assessment and history, results of physical exam, medical history, biopsychological assessment laboratory results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary, and financial information, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to an employer was signed and dated by the client on December 22, 2020 which allowed for the release of progress in treatment, treatment plans, psychological assessments, psychiatric assessment and history, results of physical exam, medical history, biopsychological assessment laboratory results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary, and financial information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #12 was admitted on August 14, 2020 and was discharged on January 8, 2021. A release of information form to a government agency was signed and dated by the client on October 20, 2020 that allowed for the release of treatment plans, psychological assessments, psychiatric history and results of physical exam, all of which exceeds the limits established by 4 Pa. Code 255.5.
This is a repeat citation from previous renewal licensing inspection completed on January 28, 2020 through January 29, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 on the proper implementation of the new release of information forms in the EMR. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to esnure that all consent to release information forms documented the dated signature of a witness in one of fourteen client records reviewed.
Client #9 was admitted on October 27, 2020 and was active at time of inspection. Release of information forms to a funding source, an individual, a urine analysis laboratory, and another treatment facility, all signed and dated by the client on October 27, 2020, did not document the dated signature of a witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Program Director and Director of Operations will train clinical staff and support staff respectively on the proper "witness" signing protocols during any clients signing of required documentation/ forms in the electronic medical record (EMR). Clinical Program Director will review the accuracy of all staff names, titles, and credentials in the EMR for "top-signing"/ "witness" signing purposes. |
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
The facility failed to ensure that all treatment plan updates were completed within the regulatory timeframe in six of seven client records reviewed.
Client #8 was admitted on September 25, 2020 and was active at the time of the inspection. A comprehensive treatment plan was completed on October 23, 2020 and an update was due no later than December 23, 2020; however, the update was not completed at the time of the inspection.
Client #10 was admitted on October 16, 2020 and was active at the time of the inspection. A comprehensive treatment plan was completed on October 30, 2020 and an update was due no later than December 30, 2020; however, the update was not completed at the time of the inspection.
Client #11 was admitted on March 5, 2020 and was discharged on November 25, 2020. A comprehensive treatment plan was completed on April 3, 2020 and an update was due no later than June 3, 2020; however, the update was not completed prior to discharge.
Client #12 was admitted on August 14, 2020 and was discharged on January 8, 2021. A comprehensive treatment plan was completed on August 24, 2020 and an update was due no later than October 24, 2020; however, the update was not completed prior to discharge.
Client #13 was admitted on August 12, 2020 and was discharged on November 30, 2020. A comprehensive treatment plan was completed on September 3, 2020 and an update was due no later than November 3, 2020; however, the update was not completed prior to discharge.
Client #14 was admitted on May 5, 2020 and was discharged on September 2, 2020. A comprehensive treatment plan was completed on June 4, 2020 and an update was due no later than August 4, 2020; however, the update was not completed prior to discharge.
This is a repeat citation from previous renewal licensing inspection completed on January 28, 2020 through January 29, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will conduct weekly chart audits of the electronic medical record (EMR) to ensure that all clients in the clinical program have their respective Master Treatment Plan updated within 60 days of signing their original Master Treatment Plan. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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
The facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven applicable client records reviewed.
Client #8 was admitted on September 25, 2020 and was active at time of inspection.
The comprehensive treatment plan, completed on October 23, 2020, indicated the client was to receive two individual sessions per week. There was no documentation in the client record of individual sessions occurring during the weeks of December 27, 2020 through January 12, 2021.
Client # 11 was admitted on March 5, 2020 and was discharged on November 25, 2020. The comprehensive treatment plan, completed on April 3, 2020, indicated the client was to receive one individual session per week. There was no documentation in the client record of individual counseling services occurring during the weeks of July 19, 2020 through the discharge date.
Client # 14 was admitted on May 5, 2020 and was discharged on September 2, 2020. The comprehensive treatment plan, completed on June 4, 2020, indicated the client was to receive one individual session per week. There was no documentation in the client record of individual counseling services occurring during the weeks of August 2, 2020 through August 22, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Program Director will conduct weekly chart audits of the electronic medical record (EMR) to ensure that all clients in the clinical program are meeting with their respective primary counselor the amount of times per week as outlined in their Initial Treatment Plan based on their ASAM level of care (PHP, IOP, or OP). Clinicians will be informed of missed sessions and placed on corrective action plans if they are deficient in this job/ clinical care requirement. Clinicians were instructed to document the reason(s) for all missed sessions (client initiated, provider schedule change, no call/ no show, etc.and a detailed follow-up plan for re-engagement) in the EMR. |
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
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 March 5, 2020 and discharged on November 25, 2020.
Client #13 was admitted on August 12, 2020 and discharged on November 30, 2020.
Client #14 was admitted on May 5, 2020 and discharged on September 2, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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. |