INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, R3 Recovery Services 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
Based on the review of personnel records, the facility failed to ensure that one clinical supervisor who had not functioned for two years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision.
Employee #2 was hired as a clinical supervisor on September 1, 2023 and was still in that position at the time of the inspection. Employee #2 did not have two years of documented clinical supervision and there was no documentation that Employee #2 completed the core curriculum training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with 704.6, the Clinical Supervisor will register for a Department-approved course with a core curriculum in clinical supervision by 6/6/24 and complete the course by 12/6/24 or before.
To ensure every Clinical Supervisor hired meets this requirement, the requirement will be discussed during onboarding for the position. The Clinical Supervisor will register for a Department-approved course with a core curriculum in clinical supervision that will be completed within the first six months of beginning that position. This ensures that all supervisors are adequately trained and meet the necessary requirements. |
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
Based on a review of two personnel records, the facility failed to document that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performances for the first six months of employment in that position.
Employee #2, who was hired as a clinical supervisor on September 1, 2023 and was still employed in that position at the time of the inspection did not have documented monthly supervision from September 2023 through February 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
To comply with 704.6, the Clinical Supervisor and Project Director will hold monthly meetings to discuss duties and performance. Starting 6/1/2024, supervision notes will be completed for the Clinical Supervisor until 12/1/24. After 12/1/24, the Project Director will determine the frequency of meetings based on the Clinical Supervisor's skill level. This information will be documented on supervision notes and kept on file.
To ensure every supervisor hired meets this requirement, the requirement will be discussed during onboarding, and a weekly supervision note will be held in the employee's file, showing supervision weekly for the first six months of employment. These meetings will discuss duties and performance. After the first six months, the frequency of meetings will be determined based on the employee's skill level. |
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
Based on a review of the personnel records, the facility failed to provide a written individual training plan per the facility ' s policy and procedure manual for each employee, appropriate to that employee's skill level in two out of two employee records reviewed. The facility ' s policy and procedure manual states that the individual training plans are due by December 31st for the upcoming training year.
Employee #1 was hired on September 1, 2023 as a project director and was still in the position as of the date of the inspection. The individual training plan is dated March 6, 2024.
Employee #2 was hired on September 1, 2023 as a clinical supervisor and was still in the position as of the date of the inspection. The individual training plan is dated March 6, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To comply with 704.11, the project director will ensure a written individual training plan for each employee, appropriate to their skill level, will be developed annually with input from both the employee and the supervisor. The facility policy and procedure manual will be updated by 6/6/2024 to require individual training plans to be completed at the time of the employee's annual review, based on their hire date. During this review, the plan will be discussed with the employee and supervisor and updated to reflect any necessary changes. |
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 administrative documents submitted, the facility failed to conduct unannounced fire drills at least once a month. There were no fire drills documented from September 2023 to the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with 705.28 Fire Safety, the Project Director will develop a procedure and form by 6/6/24 to ensure unannounced fire drills are conducted monthly, during normal staffing conditions and on all shifts. A written fire drill record will be maintained, including the date, time, evacuation duration, exit route used, number of persons present, encountered problems, and alarm operability. At the time of the drill, alternate exit routes will be reviewed, and drills will be scheduled on different days, times, and shifts as appropriate. Fire alarms or smoke detectors will be activated during each drill, and elevator use will be prohibited during drills. This form will be reviewed regularly by the Project Director to ensure compliance with 705.28. |
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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with 709.94, the Project Director created a sign with the hours of operation of the facility to be displayed conspicuously to the general public. This was addressed and completed by the Project Director on 5/22/2024. |
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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with 709.94, the Project Director created a sign with the telephone number of the facility to be displayed conspicuously to the general public for emergency purposes. This was addressed and completed by the Project Director on 5/22/2024. |