INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lewis Recovery LLC DBA Victory Park Recovery Center 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 ensure that all counselor assistants, with a high school diploma or General Education Development (GED), were counseling clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and under the close supervision of a trained counselor or clinical supervisor for the next 9 months of employment in one of four applicable personnel records reviewed. Employee # 8 was hired as a high school diploma/GED level counselor assistant on June 12, 2023. There was no documentation of supervision notes in the record during the months of June 2023 and July 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Supervision for any current counselor assistant counseling clients will be supervised by the Clinical Director at minimum weekly with additional direct observation supervision for the first 3 months of employment. Counselor assistants counseling clients will then be closely supervised for the following 9 months. The Chief Clinical Officer will oversee supervision of counselor assistants in weekly supervision with the Clinical Director to ensure this regulation is followed. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 instruct all staff in the use of the fire extinguisher upon employment in nine of nine applicable personnel records reviewed.Employee # 1 was hired as the project director on May 15, 2023. The training in the use of fire extinguishers was completed on November 10, 2023. Employee # 2 was hired as a clinical supervisor on May 15, 2023. The training in the use of fire extinguishers was completed on November 9, 2023.Employee # 3 was hired as a counselor on May 15, 2023. The training in the use of fire extinguishers was completed on November 9, 2023.Employee # 4 was hired as a counselor on July 11, 2023. The training in the use of fire extinguishers was completed on November 9, 2023.Employee # 5 was hired as a counselor on July 11, 2023. The training in the use of fire extinguishers was not completed as of the date of the inspection.Employee # 6 was hired as a counselor assistant on May 15, 2023. The training in the use of fire extinguishers was completed on November 9, 2023.Employee # 7 was hired as a counselor assistant on June 14, 2023. The training in the use of fire extinguishers was completed on November 10, 2023.Employee # 8 was hired as a counselor assistant on June 12, 2023. The training in the use of fire extinguishers was completed on November 9, 2023.Employee # 9 was hired as a counselor assistant on September 26, 2023. The training in the use of fire extinguishers was completed on November 10, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 705.28(c)(4), all new staff members will be trained on fire extinguishers with documentation the first day of employment. Fire extinguisher training has been added to new hire documentation to be completed during onboarding the first day of employment. Chief Clinical Officer or Clinical Director will sign off as witness to this training. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in nine of nine applicable personnel records reviewed.Employee # 1 was hired as the Project Director on May 15, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 2 was hired as a clinical supervisor on May 15, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 3 was hired as a counselor on May 15, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 4 was hired as a counselor on July 11, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 5 was hired as a counselor on July 11, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 6 was hired as a counselor assistant on May 15, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 7 was hired as a counselor assistant on June 14, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 8 was hired as a counselor assistant on June 12, 2023. The training in tasks to perform during emergencies was not completed as of the date of the inspection. Employee # 9 was hired as a counselor assistant on September 26, 2023. The training in tasks to perform during emergencies 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
Pursuant to 705.28(d)(3), fire safety has been added to initial trainings to be completed. The training will ensure that all staff members be trained to perform assigned tasks during emergencies. Chief Clinical Officer and Clinical Director will review trainings monthly leadership meetings to ensure all current and new staff training assessments have been identified and completed. |
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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of fourteen client records reviewed.Client # 1 was admitted to the partial hospitalization activity on July 20, 2023 and was discharged on August 14, 2023. There was evidence of disclosures to the funding source 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 any of the disclosures. Client # 2 was admitted to the partial hospitalization activity on August 15, 2023 and was discharged on September 28, 2023. There was evidence of disclosures to the funding source 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 any of the disclosures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709.28(c), informed consents for disclosure to funding sources are added to initial intake releases. In event that a client is initially treated under a scholarship, Clinical Director will check weekly to monitor if funding was approved and a release will be completed at that time. Clinical Director has been tasked with regular weekly monitoring of funding approval for clients that were admitted despite not having insurance at time of admission. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in four of fourteen client records reviewed. Client # 1 was admitted to the partial hospitalization activity on September 26, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on October 3, 2023; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made. Client # 2 was admitted to the partial hospitalization activity on August 25, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on August 25, 2023; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made. Client # 3 was admitted to the partial hospitalization activity on October 17, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on October 19, 2023; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made. Client # 14 was admitted to the outpatient activity on June 19, 2023 and was discharged on October 27, 2023. The release of information form to the funding source was signed by the client on June 19, 2023; however, the form failed to document the name of the person, agency, or organization to whom the disclosure would be made. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709.28(c)(1), Clinical Director will conduct on onsite in-house training for all staff regarding ROI requirements including person/agency/organization to whom information is to be released. This training will also be conducted with new staff upon hiring to ensure ROI have required information. Clinical Director completed an EMR audit and active client records ROI out of compliance have been adjusted, updated and voluntarily signed by clients showing person, agency and organization to whom information may be released. Admissions Director will review all new admission intakes to ensure all ROI have been completed in accordance with 709.28(c)(1). |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in fourteen of fourteen client records reviewed. In every client record reviewed, there was no documentation that a copy of any of the release of information forms were offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709.28(d), a form was added to the intake forms. The final form to be signed by a client has been added to intake forms identifying if a client would like a copy of their signed releases. The client also has the ability to choose which releases specifically they would like a copy, if they would like a copy of all releases or to deny the option of obtaining a copy. Individuals will have the option to request a copy of their releases at any time. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on an administrative review of the facility policy and procedure manual, the facility failed to include, within their medication control policy and procedures, the security of drugs including, but not limited to, the loss, theft, of misuse of drugs. After review, there were no policies and procedures regarding the security of drugs, including, but not limited to, the loss, theft, or misuse of drugs.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709(c)(5), Medication control policy has been completed by Chief Clinical Officer and Clinical director and approved by leadership. This includes policy and procedures regarding the security of drugs including but not limited to the loss, theft or misuse of drugs. Medical staff and clinical director will monitor and log any stored medications weekly to ensure medication integrity and security as well as to identify possible loss, theft or misuse. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on an administrative review of the facility policy and procedure manual, the facility failed to include, within their medication control policy and procedures, that medication errors and drug reactions shall be recorded in the client record.After review, there were no policies and procedures regarding the documentation, in the client record, of medication errors and drug reactions.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709(c)(6), Medication control policy has been completed by Chief Clinical Officer and Clinical director and approved by leadership. This policy includes the procedure regarding the documentation of medication errors and drug reactions in the client record. Medical staff will document any medication errors and drug reactions within the medical chart of client record. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to assure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in four of seven applicable client records. Client # 2 was admitted to the partial hospitalization activity on August 25, 2023 and was still active at the time of the inspection. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the weeks of September 3, 2023 through September 9, 2023, October 1, 2023 through October 7, 2023, October 15, 2023 through October 28, 2023 and November 5, 2023 through November 11, 2023. Client # 4 was admitted to the partial hospitalization activity on August 17, 2023 and was discharged on September 14, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the week of August 13, 2023 through August 19, 2023. Client # 6 was admitted to the partial hospitalization activity on July 11, 2023 and was discharged on August 20, 2023. The record of service and progress notes indicated that individual counseling sessions occurred once a week, rather than twice a week, during the weeks of July 23, 2023 through August 5, 2023. Client # 7 was admitted to the partial hospitalization activity on July 20, 2023 and was discharged on August 14, 2023. The record of service and progress notes indicated that there were no individual counseling sessions during the weeks of July 23, 2023 through July 29, 2023 and August 6, 2023 through August 12, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer and Clinical Director met with clinical staff regarding regulations for partial hospitalization specifically regulations for individual counseling to be completed twice weekly. Staff was advised that a missed session note is required for any individual who is not met with twice each week explaining the reason for a missed session. Clinical Director will meet with staff during weekly staff meetings to ensure that all documentation has been completed. |
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
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in one of two applicable client records reviewed. Client # 14 was admitted to the outpatient activity on June 9, 2023 and was discharged on October 27, 2023. The individual treatment plan was completed on August 9, 2023 and the first update was due no later than October 9, 2023; however, the update was not completed prior to discharge. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Pursuant to 709.92(b), Clinical Director will complete a weekly chart audit including treatment planning to ensure that treatment plans are reviewed and updated no more than 60 days from initialization of the treatment plan. Clinical staff met for in house SOP training regarding the need to review and update treatment plans no more than 60 days from the date the treatment plan was collaboratively developed. |
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 maintain a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.Client # 11 was admitted to the outpatient activity on August 15, 2023 and was discharged on September 28, 2023. There was no follow-up information documented as of the date of the inspection. Client # 13 was admitted to the outpatient activity on May 17, 2023 and was discharged on June 21, 2023. There was no follow-up information documented as of the date of the inspection.Client # 14 was admitted to the outpatient activity on June 19, 2023 and was discharged on October 27, 2023. There was no follow-up information 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
Pursuant to 709.93(a)(11), Chief Clinical Officer and Clinical Director created an SOP for outreach to be completed for all discharged clients to be contacted as follow-up. The contacts will be added to EMR system identifying client's MR record number, date/time of contact and any additional information necessary for continuity of care including but not limited to any resources needed, referrals or need for additional treatment. |