INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rosewood Recovery, 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(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 three personnel records, the facility failed to ensure that one employee had a written individual training plan that was developed annually.
Employee # 2 was hired as a counselor on May 27, 2024 and was current in that position at the time of the inspection. Employee # 2 should have had an initial individual training plan developed within 30 days of the date of hire, however a written individual training plan was not developed until July 9, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/28/2024, the Project Director has revised the new hire orientation checklist to include a 30-day due date alert for the individual training plan. To ensure timely completion, the Project Director or the assigned supervisor will review the checklist with each new hire on a weekly basis. |
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 three personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.
Employee # 2 was hired as a counselor on May 27, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until June 12, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/28/2024, the Project Director has revised the new hire orientation checklist to include a 7-day due date alert for the fire extinguisher training. To ensure timely completion, the Project Director or the assigned supervisor will review the checklist with each new hire on a weekly basis. |
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 fire drill logs from September 2023 through June 2024, the facility failed to conduct an unannounced fire drill during December 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 28, 2024, the Project Director will establish monthly reminders for fire drills. At the beginning of each month, the Project Director will schedule a specific day and time for the fire drill on their calendar. |
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 three personnel records, the facility failed to ensure that one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 2 was hired as a counselor on May 27, 2024 and is current in that position. Employee # 2 began working shifts on May 27, 2024, but was not trained to perform assigned tasks during emergencies until June 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 28, 2024, the Project Director has updated the new hire orientation checklist to include a 7-day due date alert for emergency management training. To ensure timely completion, the Project Director or the assigned supervisor will review the checklist with each new hire on a weekly basis. |
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 fifteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in ten records reviewed.
Client # 2 was admitted to the Partial level of care on March 11, 2024 and was transferred to a lower level of care on April 1, 2024. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on February 29, 2024, did not allow for the release of that information.
Client # 3 was admitted to the Partial level of care on June 3, 2024 and was transferred to a lower level of care on July 1, 2024. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on June 3, 2024, did not allow for the release of that information. Additionally, the record contained documentation of identifying information and lab work released to an outside laboratory on June 19, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 4 was admitted to the Partial level of care on May 28, 2024, and was discharged on August 5, 2024. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on May 28, 2024, did not allow for the release of that information. Additionally, the record contained documentation of identifying information and lab work released to an outside laboratory on June 12, 2024, June 25, 2024, July 10, 2024, July 17, 2024, and July 26, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 5 was admitted to the Partial level of care on May 21, 2024 and was discharged on June 17, 2024. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on May 21, 2024, did not allow for the release of that information. Additionally, the record contained documentation of identifying information and lab work released to an outside laboratory on June 13, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 6 was transferred to the Partial level of care on August 1, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on June 25, 2024, did not allow for the release of that information. Additionally, the record contained documentation of identifying information and lab work released to an outside laboratory on June 26, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 7 was admitted to the Partial level of care on August 8, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on August 8, 2024, did not allow for the release of that information.
Client # 8 was transferred to the Outpatient level of care on June 6, 2024 and transferred to a higher level of care on August 8, 2024. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on May 1, 2024, did not allow for the release of that information.
Client # 11 was admitted to the Outpatient level of care on August 24, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on August 24, 2023, did not allow for the release of that information. Additionally, the record contained documentation of identifying information and lab work released to an outside laboratory on January 2, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 12 was admitted to the Outpatient level of care on March 22, 2024, and was discharged on July 24, 2024. Per a discussion with the Facility Director, information such as client ' s diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on March 22, 2024, did not allow for the release of that information. Additionally, there was evidence of a disclosure to a family member during a family counseling session on June 5, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 15 was admitted to the Outpatient level of care on September 18, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client ' s diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on September 18, 2023, did not allow for the release of that information. Additionally, the record contained documentation of identifying information and lab work released to an outside laboratory on August 9, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 22, 2024, the Project Director requested Service Agreements from both laboratories. The Project Director signed both agreements on or before August 26, 2024. One laboratory has already countersigned, and the executed agreement has been filed. The second laboratory is expected to countersign by the end of September. The Project Director will follow up weekly until the signed document is received and filed.
On August 22, 2024, the Project Director updated the release of information template for funders to include the release of diagnoses. All current clients are required to complete a new release of information form by September 30, 2024.Since the template for these releases now include diagnoses, this citation will not be repeated.
During the staff meeting on August 22, 2024, the Project Director reviewed the updated release of information procedures, emphasizing the importance of verifying that a release is on file before proceeding with any family sessions. As family sessions occur, Project Director will remind staff to ensure a release is on file to ensure this citation is not repeated. Additional reminders will occur in regular supervisions.
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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 provide individual counseling sessions two times weekly for clients in the partial hospitalization activity in four of seven client records reviewed.
Client # 2 was admitted to the Partial level of care on March 11, 2024 and was transferred to a lower level of care on April 1, 2024. The record contained documentation of only one individual counseling session for the week of March 11, 2024.
Client # 4 was admitted to the Partial level of care on May 28, 2024, and was discharged on August 5, 2024. The record contained documentation of only one individual counseling session for the weeks of June 10, 2024 and June 17, 2024.
Client # 5 was admitted to the Partial level of care on May 21, 2024 and was discharged on June 17, 2024. The record contained documentation of only one individual counseling session for the week of May 27, 2024.
Client # 6 was transferred to the Partial level of care on August 1, 2024 and was active at the time of the inspection. The record contained documentation of only one individual counseling session for the week of August 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 22, 2024, the Project Director discussed the importance of documenting no-shows and cancellations for scheduled individual sessions during a staff meeting. Moving forward, the Project Director will review documentation for partial hospitalization clients during weekly supervision to ensure compliance. |