INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2014 and October 21, 2014 by staff from the Division of Drug and Alcohol 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document the required close supervision and direct observation for counselor assistants in three of three personnel records reviewed.
The findings include:
Three personnel records of counselor assistants requiring documentation of supervision were reviewed during the renewal inspection on 10/20/2014. The facility failed to document either direct observation or close supervision in personnel records # 9, 10 and 11.
Employee # 9 was hired on 6/12/2013 and promoted to a bachelor's level counselor assistant on 8/25/2014. The facility failed to document one hour of direct observation per week as part of the weekly close supervision from 8/25/2014 - 10/20/2014.
Employee # 10 was hired on 9/9/2013 as a bachelor's level counselor assistant. The facility failed to document one hour of direct observation per week as part of the weekly close supervision from 9/9/2014 - 10/20/2014.
Employee # 11 was hired on 7/29/2013 and promoted to a high school diploma level counselor assistant. The facility failed to document direct observation as part of the weekly direct supervision from 7/29/2014 - 10/20/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0049
The facility has taken the following steps to assure that this deficiency does not recur.
A log book for each Counselor Assistant has been established and has a specific outline stating the supervision required for each Counselor Assistant based upon their educational degree to achieve promotion to Counselor status.
Forms have been created for group or individual session to be filled out reflecting direct or close supervision in those settings. These forms are collected and reviewed at the Counselor Assistant's weekly supervision meeting with Albert Ciliberto. These forms are kept in the Log Book for the Counselor Assistant and is reviewed on a weekly basis in a meeting held between Albert Ciliberto, Clinical Director, Michelle Olmeda, Director of Compliance and Gregory Varley, Executive Director. This process will continue until each Counselor Assistant reaches the required supervision and can be promoted to Counselor status.
In the future if there is an individual who is placed in a Counselor Assistant position at the time of that placement a comprehensive assessment and supervision plan will be created. This plan will be scheduled where the Counselor Assistant and the Clinical Supervisor will have their weekly meeting and supervision forms will be placed in that Counselor Assistant's log book. This log book will be reviewed as part of the weekly meeting between the Executive Director, the Clinical Director and the Director of Compliance.
We currently have increased the level of close supervision on the two Counselor Assistants with Bachelor's degrees. This supervision will include patient groups and individual sessions that will directly be observed by a CADC level Counselor or Clinical Supervisor at least 1 hour per week. This supervision will also include morning group level supervision and weekly one hour individual supervision sessions. This will be documented and transpire over a six month period.
The Counselor Assistant who has a high school diploma will have Direct Observation during their facilitation of patient groups and individual sessions by a CADC level Counselor or a Clinical Supervisor. This will be documented on forms for either group or individual sessions and transpire for a 3 month period. After that 3 months of Direct Observation they will move into a 9 month Close Supervision (as previously described) which will be documented.
The individuals responsible for assuring this supervision takes place and is properly documented are Albert Ciliberto, CADC, CCS, Clinical Director, Michelle Olmeda, Director of Compliance and Gregory Varley, LCADC, CCS, Executive Director.
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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 personnel records, the facility failed to provide documentation of individual training plans in two of eleven personnel records reviewed.
The findings include:
Eleven personnel records requiring documentation of individual training plans were reviewed during the renewal inspection on 10/20/2014. The facility failed to provide documentation of individual training plans for the current training year in personnel records # 1 and 9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0063
To ensure that this deficiency does not recur the facility will conduct the creation of an Individual Training Plan at the same time as the employees Annual Review is conducted. Both forms will be filled out by the Department Supervisor with the employee, who will sign both forms and receive copies. These will be countersigned by Michelle Olmeda, Director of Compliance. The Individual Training Plans will be returned to Ms. Danielle Schneider who will put the form in the employee's personnel file and signal her computer to alert her to audit the employees compliance with what has been identified as needed trainings on their training plan within the allotted time.
Training Plans for new hires will be developed by the employee's department supervisor within one week of the individual's being hired. These plans will be countersigned by Michelle Olmeda, Director of Compliance and returned to Ms. Schneider who will place it in the employee's personnel record and set up an alert on her computer for compliance audit purposes.
Ms. Schneider will audit all personnel records for compliance during the month of September each year.
Individual Training Plans have been completed for each employee appropriate to their skill level. Where necessary these plans include mandatory Communicable Disease trainings of six (6) hours HIV/AIDS and four (4) hours of TB/STD training using a DDAP approved curriculum. This training will be completed for all employees and properly documented within the appropriate time allocations for clinical and non-clinical staffs. Employee #1 and #9 have completed Individual Training Plans.
The responsible parties that assured that this has been complete and will continue to be accomplished are Michelle Olmeda, Director of Compliance, Albert Ciliberto, CADC, CCS, Clinical Director and Gregory Varley, LCADC, CCS, Executive Director.
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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 and training records, the facility failed to provide documentation of mandatory communicable disease training in three of seven personnel records reviewed.
The findings include:
Seven personnel records requiring documentation of mandatory communicable disease training were reviewed on 10/20/2014. The facility failed to provide documentation of communicable disease training in personnel records # 3, 10, and 14.
Employee # 3 was hired on 2/1/2013 as a counselor. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training by 2/1/2014. Employee # 3 failed to obtain the training as of the date of the inspection.
Employee # 10 was hired on 9/9/2013 as a counselor assistant. This employee was required to obtain four hours of TB/STD training by 9/9/2014. Employee # 10 failed to obtain the training as of the date of the inspection.
Employee # 14 was hired on 8/1/2012 as a recreation director. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training by 8/1/2014. Employee # 14 failed to obtain the training 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
L0067
The facility will take the following steps to ensure this deficiency does not recur. Both a six (6) hour HIV/AIDS and a four (4) hour TB/STD training will be presented at PMRC each training year. Ms. Schneider and Ms. Olmeda in conjunction with Mr. Ciliberto will arrange for these trainings to be scheduled. A list of all employees in need of this training will be prepared by Ms. Schneider from her recent audit of all personnel files of current employees and amended as any new hires present needing this training. In the event that any employee needing these trainings cannot attend the PMRC training they will be given the dates when this training is available at a different location for themselves to schedule. Failure to obtain the necessary training and submit documentation within the allocated time will result in disciplinary action. All documentation is to be submitted to Ms. Schneider, Human Resources Supervisor. Ms. Schneider will audit all personnel records for compliance during September of each year. The individual's responsible to supervise Ms. Schneider on this are Michelle Olmeda, Director of Compliance, Albert Ciliberto, Clinical Director and Gregory Varley, Executive Director.
Employee #3, Counselor currently has his six (6) hour HIV/AIDS training certificate in his personnel file. He is enrolled in a four (4) hour TB/STD course scheduled for December 11, 2014. This course uses a DDAP approved curriculum.
Employee #10, Counselor Assistant is scheduled to take a four (4) hour TB/STD training on December 16, 2014 that has a DDAP approved curriculum.
Employee #14, Recreation Director is scheduled to attend a six (6) hour HIV/AIDS training on December 11, 2014 and a four (4) hour TB/STD training on December 16, 2014.
The people responsible for assuring the above employees will receive this training and that certificates are in the personnel file are Albert Ciliberto, Clinical Director, Michelle Olmeda, Director of Compliance and Gregory Varley, Executive Director.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the facility director's personnel record, the facility failed to document the completion of 12 clock hours of annual training required for the facility director.
The findings include:
The facility director's personnel record was reviewed during renewal inspection on 10/20/2014 for the requirement of the completion of 12 clock hours of annual training. The facility failed to document the completion of 12 clock hours of annual training for employee # 1.
Employee # 1 was hired on 7/5/2013 as the facility director. The facility's training year is from July through June. The training year for July 2013 to June 2014 was reviewed. Employee # 1 did not complete any annual training for the July 2013 to June 2014 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0075
To ensure this deficiency does not recur the Facility Director will be required to schedule their 12 hours of annual training at the time of their annual review and training plan development. The Human Resources Supervisor, Danielle Schneider will conduct an audit of all personnel files during the month of September each year; including that of the Project Director, to assure compliance with having 12 hours of documented trainings for the Project Director each year. Ms. Michelle Olmeda is responsible to supervise Ms. Schneider's audit of the Project Director's personnel file.
The Project Director has obtained a fifteen (15) hour training program on Geriatric Addiction Treatment Issues and Practices from Le Bann's trainings. This will be completed by November 28, 2014.
The persons responsible to assure that this training is completed and the certificate documenting it are in the Project Director's personnel file are Albert Ciliberto, Clinical Director and Michelle Olmeda, Director of Compliance.
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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 personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel record reviewed.
The findings include:
One personnel record of a counselor requiring the documentation of the completion of 25 clock hours of annual training was reviewed on 10/20/2014. The facility failed to document the completion of 25 clock hours of annual training for employee # 3.
Employee # 3 was hired on 2/1/2013 as a counselor. The facility training year is from July through June. The training year for July 2013 to June 2014 was reviewed. Employee # 3 did not complete any annual training for the July 2013 to June 2014 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0083
To ensure this deficiency does not recur the facility has instituted the policy that each employee will create with their department supervisor a training plan for their training year. This training plan will be developed at the time of the employee's annual review, or within the first week of a new employee being hired as part of their hiring process. Whatever mandatory trainings are needed for that individual will be included in their yearly training plan. A computer program is being set up that will assist the Human Resources Supervisor, Ms. Schneider, to track the people needing these mandatory trainings and alert them to schedule their trainings. This computer program will also track when documentation is submitted regarding mandatory trainings and annual required training hours for all staff, Counselors and the Project Director. This computer program will send an alert to Ms. Schneider if requirements of the training plan are unfulfilled in a timely manner. The employee will be supervised regarding this area of deficiency. This computer program will be cross checked by an annual audit of all personnel files during the month of September each year that will be conducted by the Human Resources Supervisor. The Counselors, Project Director and other PMRC employees will be responsible to schedule their own attendance at trainings. A schedule of trainings for PMRC, Clearbrook Manor and the DDAP training management system website will be given to the staff that needs mandatory trainings or training hours.
Ms. Schneider, Human Resources Supervisor, Michelle Olmeda, Director of Compliance and Albert Ciliberto, Clinical Director will be responsible to ensure oversight of this schedule, implement action and documentation of trainings of staff.
Employee #3 has enrolled in a six (6) hour HIV/AIDS on December 11, 2014. He will also be enrolled in a twenty-one (21) hour training over the course of six sessions on Mindfulness Acceptance Based Therapeutic Intervention Techniques scheduled to begin on November 13 and conclude on December 18, 2014. These hours will remediate the required twenty-five (25) hours for the period of July 2013 to June 2014. Employee #3 will also be supervised to complete twenty-five (25) hours of training for the July 2014 to June 2015 training period.
The persons responsible to assure that these trainings of twenty-five (25) hours to remediate the July 2013 to June 2014 period and to assure that the twenty-five (25) hours are completed by the June 2015 deadline will be Albert Ciliberto, Clinical Director and Michelle Olmeda, Director of Compliance, Gregory Varley, Executive Director. These courses will be appropriate to the function of his job as a lead Counselor supervising other Counselors.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of fire extinguishers upon employment in three of six personnel records reviewed.
The findings include:
Six personnel record requiring the documentation of fire extinguisher training was reviewed during the renewal inspection on 10/20/2014. The facility failed to document the completion of fire extinguisher training upon employment in personnel records # 5, 7 and 8.
Employee # 5 was hired on 4/28/2014 as a counselor. There was no documentation that Employee # 5 completed the fire extinguisher training as of the time of the review.
Employee # 7 was hired on 4/28/2014 as a counselor. There was no documentation that Employee # 7 completed the fire extinguisher training as of the time of the review.
Employee # 8 was hired on 9/8/2014 as a counselor. There was no documentation that Employee # 8 completed the fire extinguisher training as of the time of the review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P139
The plan of correction was implemented during the onsite licensure renewal inspection conducted on October 20, 2014 and October 21, 2014. Employees #5, #7 and #8 signed documentation of their having received Fire Extinguisher training at the time of their being employed. These documents are currently in their personnel file. All personnel files have been reviewed to see if there was any employee that needed this training and subsequent documentation.
To ensure this deficiency does not reoccur the training for the fire extinguisher use and emergency procedures is now to be completed within one week from the date of hire. The Operations Manager, Mr. Thomas Cannon, will conduct this training and documentation of all new hires. Ms. Danielle Schneider, Human Resources Supervisor, will be responsible to ensure the timely completion and filing of this documentation of this training for all new hires. Ms. Schneider has audited all the current personnel files to assure that every current employee has had this training and that it is documented, stored in the individual's personnel record. All new hire records will be audited at the conclusion of ninety days probationary period to assure that trainings have been completed and documented. Ms. Schneider will be supervised in this capacity by Michelle Olmeda, Director of Compliance and Gregory Varley, Executive Director.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services during the renewal inspection on 10/20/2014. The facility's fiscal year runs from January 1 to December 31.
The facility did not complete an independent financial audit for the 2013 fiscal year. Additionally, the facility failed to produce documentation that an independent financial audit was conducted for the 2012 fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0169
Fiscal Management. Pocono Mountain Recovery Center has obtained the services of an independent public accountant for the annual audit of financial facilities for the fiscal year that goes from January 1, 2014 through December 31, 2014.The results of this financial audit will be prepared in January 2015 and submitted to the State of Pennsylvania Department of Drug and Alcohol Programs Licensure by February 2, 2015.
The persons who are responsible to assure that this annual audit is filed are Craig Odiorne, Chief Financial officer and Gregory Varley, Executive Director.
To assure this deficiency does not recur Pocono Mountain Recovery Center will have a financial audit prepared by an independent accounting firm at the conclusion of every fiscal year January 1st to December 31st that PMRC is in operation. This audit will be required to be completed, on file, ready for submission by February 14th of every year PMRC is in operation.
The parties responsible for ensuring that future annual audits are completed by February 14th of each year going forward are Craig Odiorne, Chief Financial Officer and Gregory Varley, Executive Director.
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records, the facility failed to document employee notification of rights in four of five personnel records reviewed.
The findings include:
Five personnel records were reviewed for documentation of the employee notification of rights during the renewal inspection on 10/20/2014. The facility failed to provide documentation of the notification of rights in personnel records # 4, 5, 7 and 8.
Employee # 4 was hired as a counselor on 5/12/2014. The personnel record did not contain documentation of the employee being notified of their rights at the time of the review.
Employee # 5 was hired as a counselor on 4/28/2014. The personnel record did not contain documentation of the employee being notified of their rights at the time of the review.
Employee # 7 was hired as a counselor on 4/28/2014. The personnel record did not contain documentation of the employee being notified of their rights at the time of the review.
Employee # 8 was hired as a counselor on 9/8/2014. The personnel record did not contain documentation of the employee being notified of their rights at the time of the review.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0233
The plan of correction was implemented during the onsite licensure renewal inspection conducted on October 20, 2014 and October 21, 2014. Employees #4, #5, #7 and #8 signed the documentation of their being notified of their rights.
All current personnel files have been checked to assess if there are any other employees that needed documentation of their rights.
To ensure that this deficiency does not reoccur every new employee will review the Employee Handbook at the time of being hired. Upon their review they will complete the document indicating that they know their rights as an employee of PMRC. Ms. Danielle Schneider, Human Resources Supervisor, is responsible to ensure that the process is completed in a timely manner and the documentation is in the employee's personnel record. All new hire records will be audited at completion of the new hire's ninety day probationary period to assure that each employee has documentation of their understanding of their rights. Ms. Schneider will be supervised in respect to this part of her job by Michelle Olmeda, Director of Compliance and Gregory Varley, Executive Director.
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