INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 7, 2024 through November 8, 2024 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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704.11(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 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 training within the regulatory timeframe in one of nine applicable personnel records reviewed.
Employee # 11 was hired as a behavioral health technician on February 14, 2022 and was due to have the TB/STD training no later than February 14, 2024; however, the TB/STD training was completed on April 3, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Human resources personnel will conduct quarterly employee file audits to ensure training compliance among Pennsylvania Recovery Center staff. When auditor recognizes a training due within the next quarter they will notify the individual in need of training and their direct supervisor via email. The following audit will ensure this training was completed or corrective action will be taken by Clinical Director.
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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 a review of the facility's January 2024 through November 2024 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
At the time of the inspection, there was no fire drill documented and conducted during the month of June 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Safety officer will conduct unannounced monthly fire drills separate from other emergency preparedness drills. Compliance Director will review fire drills the last week of each month to ensure completion. If at that time the drill has not yet been completed, Compliance Director will communicate need to Safety Officer and review fire drill upon completion.
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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 2024 through November 2024 fire drill logs, the facility failed to maintain a complete written fire drill record, which is to include the exit route used during the fire drill.
The October 2024 fire drill log was missing documentation of which exit route was used during the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Safety officer will update the fire drill log form to include the exit route. Safety officer will also ensure fire drill logs are completed in their entirety. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's January 2024 through November 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation are posted as Monday through Friday from 9:00 AM to 9:00 PM. Every monthly fire drill reviewed was conducted between the hours of 12:45 PM and 7:00 PM and there were no fire drills conducted during the facility's morning hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Operating Officer will update facility safety policy (4.02) to specifically state that fire drills will be conducted on different days of the week, at different times of the day and on different staffing shifts. Prior to completing the monthly drill, Safety Officer will review the previous month's drill and be sure to select a different time of day. Compliance Director will review fire drills the last week of each month to ensure compliance. If at that time drill has been completed for the month and did not occur at an alternate time of day, Compliance Director will communicate the need for an additional drill to the Safety Officer. |
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 the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on August 12, 2024 and was administratively discharged on August 22, 2024. There was no documentation in the record indicating the client was given written notification of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the weekly clinical team meeting on December 19th, 2024, Director of Clinical Services will reeducate the clinical staff in Administrative Discharge procedure. The Clinical Director will be responsible for reviewing charts of clients that were administratively discharged within 5 days of discharge to ensure that the letter was sent. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in one of three applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on September 23, 2024 and was still active. The individual treatment plan was completed on October 1, 2024 and the first update was due no later than November 1, 2024; however, there was no treatment plan update completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1's treatment plan was updated on November 8th, 2024. During the weekly Clinical Team meeting on December 12th, 2024 the Director of Clinical Services reeducated the clinical staff on treatment plan policies and procedures. The leadership team will also work conjunctively to audit charts every two weeks to ensure treatment plans are updated every 30 days. |