INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 25, 2021 through February 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bradford 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:
|
Plan of Correction
|
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
|
Observations
Based on the review of personnel records, the project failed to document a written semiannual performance evaluation based upon measurable performance standards for one applicable employee.
Employee #6 was hired as a counselor assistant on May 29, 2020 and was due to have a written semiannual performance evaluation completed no later than November 29, 2020; however, there was no semiannual performance evaluation documented in the personnel record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Upon review of personnel records, Employee #6 (Counselor Assistant), did not have a semiannual performance plan completed prior to November 29, 2020. The Clinical Director will receive education on the state requirements (704.9 (b), regarding performance evaluation by April 5th 2021. The Clinical Directors' proof of education will be documented in the staff members personnel file. The Clinical Director will complete semiannual performance evaluations with all Counselor Assistants. The evaluations will be placed in the employee personnel file. The HR Manager will complete weekly audits of all Counselor Assistant personnel files and provide an updated list of upcoming evaluations at the weekly Leadership meeting to ensure compliance. |
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.
|
Observations
Based on the review of personnel records, the project failed to ensure that one applicable employee counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment.
Employee #6, a counselor assistant with a Bachelor ' s Degree, hired on May 29, 2020, was to receive close supervision for the first six months of employment (one hour per week of case review and one hour per week of director observation); however, there was no documentation of close supervision in the personnel record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Plan of Correction:
Upon review of personnel records, Employee #6 (Counselor Assistant), did not have documented close supervision for the first 6 months of employment. The Clinical Director will receive education on the state requirements (704.9 (c), regarding supervision of counselor assistants by April 5th 2021. The Clinical Directors' proof of education will be documented in the staff members personnel file. The Clinical Director will complete 6 months of close supervision with all Counselor Assistants. The supervision will be documented and placed in the employees personnel file. The HR Manager will complete weekly audits of all Counselor Assistant personnel files and provide an updated list of upcoming evaluations at the weekly Leadership meeting to ensure compliance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on the physical plant inspection, conducted on February 26, 2021, the facility failed to ensure that the hot water temperatures did not exceed 120 degrees Fahrenheit.
When using a thermometer, the water temperature in the detox bathroom, measured at 128.2 degrees Fahrenheit.
When using a thermometer, the water temperature in the women ' s bathroom outside of the cafeteria, measured at 129.5 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The Facility Grounds Manager will conduct monthly water testing in 2 different areas of the facility to ensure the facilities hot water temperature does not exceed 120°F. The Facility Grounds Manager will track the monthly testing on a spreadsheet and a file maintained. The monthly testing results will be discussed at the monthly Risk Management meeting and the spreadsheet signed off by the Risk Manager.
This correction has been fully implemented within the facility.
|
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seventeen client records reviewed.
Client #8 was admitted on May 9, 2020 and was discharged on June 8, 2020. There was correspondence between facility staff members and a county court documented in the records on June 23, 2020; however, there was no proper consent to release information form signed by the client prior to disclosure. Additionally, there was correspondence between facility staff members and a judge documented in the records on June 24, 2020; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Plan of Correction:
Upon review it is noted that in one client file, the facility did not obtain consent to disclose information. The document reviewed belonged to another client. The facility will ensure that all client records are maintained and will only include information for that specific client. Facility administration, clinical, medical and admissions staff will be reminded to be cautious when placing documentation in client EMR files. The discussion will be documented via department meeting sign in sheets and placed in staff personnel files. The facility leadership team will complete 5 biweekly chart audits to maintain compliance. Noncompliance concerns will be discussed at the weekly Leadership team meeting for further evaluation and corrective action. |
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.
|
Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seventeen client records reviewed.
Client #2 was admitted on June 21, 2020 and was discharged on August 26, 2020. A release of information form to a county mental health agency, signed and dated by the client on June 21, 2020, allowed for the release of verbal/written medical records, past medical history, verbal and written reports, diagnosis and symptoms of diagnosis and recovery environmental information, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #11 was admitted on November 6, 2020 and was discharged on December 3, 2020. On December 3, 2020, it was documented in the record that the discharge summary and aftercare plan were sent to court officials. These disclosures exceed the limits established by 4 Pa. Code 255.5.
Client #13 was admitted on February 1, 2021 and was a current client at the time of the inspection. A release of information form to a county mental health agency, signed and dated by the client on February 1, 2021, allowed for the release of verbal/written medical records, past medical history, verbal and written reports, diagnosis and symptoms of diagnosis and recovery environmental information, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The facility shall ensure disclosure of client identifying information are within the limits established by PA Code 255.5. No clients listed in the deficiency are currently active. Client #13 discharged on 2-26-21, the facility is unable to update the release. Clients, as identified in the deficiency, will be provided written notification of noncompliance with PA Code 255.5 disclosure of information by 4-5-2021. The facility will check all current clients to ensure PA 255.5 compliance. Facility staff will receive refresher Confidentiality and PA Code 255.5 training by April 5th 2021. Staff certification of completions will be maintained in employee personnel files. The facility leadership team will complete 5 biweekly chart audits to maintain compliance. Noncompliance concerns will be discussed at the weekly leadership team meeting for further evaluation and corrective action.
|
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.
|
Observations
Based on the review of client records, the project failed to notify a client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one applicable client record reviewed.
Client #2 was admitted on July 21, 2020 and was involuntarily terminated from treatment on August 26, 2021. There was no documentation in the record that the client had been notified in writing of the project ' s decision to terminate the client ' s treatment.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The facility has created a Notification of Termination form within the EMR. The Notification of Involuntary Termination of Treatment document has been implemented. On March 16th 2021, all clinical and medical facility staff were informed and educated on utilizing the form for all clients being involuntarily discharged from treatment. Documentation of the information and education received will be placed in staff personnel files. All involuntary discharged clients will be provided a Notification of Involuntary Termination of Treatment letter at discharge. This document will be included in the discharge paperwork provided to the discharging client. The document will be signed by facility staff and client, then will be scanned into the client file. To ensure compliance, the Notification of Termination letter has been added to the facility chart audit form. The leadership team will complete 5 biweekly chart audits and noncompliance concerns will be discussed at the weekly leadership meeting for further evaluation and corrective action. |
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.
|
Observations
Based on the review of client records, the project failed to ensure that clients in the partial hospitalization program receive individual counseling at least twice weekly in three of seven applicable records reviewed.
Client #3 was admitted on September 25, 2020 and was discharged on February 8, 2021. The client was missing one of the two required individual counseling sessions for the weeks of December 20, 2020 through December 26, 2020, December 27, 2020 through January 2, 2021 and January 10, 2021 through January 16, 2021.
Client #5 was admitted on December 22, 2020 and was a current client at the time of the inspection. The client was missing one of the two required individual counseling sessions for the weeks of December 27, 2020 through January 2, 2021, January 17, 2021 through January 23, 2021, January 24, 2021 through January 30, 2021 and February 7, 2021 through February 13, 2021.
Client #6 was admitted on January 20, 2021 and was a current client at the time of the inspection. The client was missing one of the two required individual counseling sessions for the weeks of January 24, 2021 through January 30, 2021 and February 14, 2021 through February 20, 2021.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Plan of Correction:
Upon review of partial hospitalization client records, it is noted that three client records were missing one of the required two weekly individual counseling sessions. The Clinical Director will meet with all partial hospitalization counselors and provide education on program requirements and compliance (709.82 (d)(1). The education will be provided by April 5th 2021 and documentation placed in the staff members personnel file. The facility leadership team will complete 5 biweekly chart audits to maintain compliance. Noncompliance concerns will be discussed at the weekly Leadership team meeting for further evaluation and corrective action. |