INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1 and 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Oil Region Recovery, Inc. 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(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 training documentation records and the facility ' s Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable records.
Employee # 5 was hired as a cook on November 28, 2018 and was due to have the HIV/AIDS and TB/STD training no later than November 28, 2020. The HIV/AIDS and the TB/STD training documentation was not available at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review training hours quarterly and schedule the required trainings to ensure that Oil Region Recovery staff maintain all required trainings. Oil Region Recovery mission is to ensure that all staff are trained appropriately and are proficient at their respective positions |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection on June 2, 2022, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating in two of the three buildings on the campus.
There were no fire extinguishers in one residential building (Building 4) and in the Group Building.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Fire extinguishers have been placed in the south dorm at both exits. The kitchen also had new fire extinguishers placed in the appropriate locations to be utilized best in case of an emergency. A fire extinguisher was placed in the group building within the standard safety distance to each exit. All fire extinguishers were contracted to be placed in the appropriate locations, except 2 ABC and the special kitchen were at our previous location and they needed relocated to current location. The fire extinguishers are contracted to company to review and recharge fire extinguishers as needed to ensure that all extinguishers remain update and in the proper location |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection on June 2, 2022, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Fire extinguishers have been placed in the south dorm at both exits. The kitchen also had new fire extinguishers placed in the appropriate locations to be utilized best in case of an emergency. A fire extinguisher was placed in the group building within the standard safety distance to each exit. All fire extinguishers were contracted to be placed in the appropriate locations, except 2 ABC and the special kitchen were at our previous location and they needed relocated to current location. The fire extinguishers are contracted to company to review and recharge fire extinguishers as needed to ensure that all extinguishers remain update and in the proper location |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to have the annual written individual staff performance evaluation reviewed and signed by the employee in one of two applicable personnel records.
Staff #4 was hired on July 23, 2018 and promoted on July 16, 2019. An annual performance evaluation was dated and signed by the supervisor on July 16, 2021 but was not signed by the employee.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff charts will be reviewed by the human resources director to ensure all charts are in compliance with DDAP regulations. The first line supervisor is required to write employee reviews and the human resources will review employee files. |
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 obtain an informed and voluntary consent from the client prior to disclosure of information in one of seven client records.
Client # 5 was admitted on May 19, 2022 and was active at the time of the inspection. The client record included documentation of disclosure to an Apothecary occurred on May 23, 2022, but there was not a release of information signed by the client.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Administrative Director has submitted a quality service agree to the outside organization. The quality service agree was return and client confidentiality is now being meant. Administrative Director will ensure that all outside agencies from this point forward will have a quality service agreement. Counselors, Administrative staff, and all other staff members will ensure that a release of information or quaility service agreement will be signed before any outside communication about a client. The clinical supervisor will review charts and release of information to ensure this is happening correctly |
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 indicate the name of the person, agency or organization on a release of information form in one of seven client records.
Client # 7 was admitted on May 23, 2022 and was active at the time of the inspection . A release of information was signed by the client and the witness on May 23, 2022, but the release form was blank for the person, agency, organization.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The counselors will be required to review their charts upon being assigned a client to ensure the admission paper work was completed correctly. The clinical director will review charts and review all consents to ensure they are completed correctly. |
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.
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Observations
Based on a review of client records, the facility failed to indicate the specific information to be disclosed on a release of information form in one of seven client records.
Client # 5 was admitted on May 19, 2022 and was active at the time of the inspection. A release of information was signed by the client on May 19, 2022, but the release did not indicate the specific information to be disclosed.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The counselors will be required to review their charts upon being assigned a client to ensure the admission paper work was completed correctly. The clinical director will review charts and review all consents to ensure they are completed correctly. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms for one of seven client records.
Client #3 was admitted on April 8, 2022 and discharged on May 5, 2022. Release of information forms; three to government agencies and one to an individual, were signed by the client but do not include a date of the client signature. All four release forms have a witness signature dated April 8, 2022.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The counselors will be required to review their charts upon being assigned a client to ensure the admission paper work was completed correctly. The clinical director will review charts and review all consents to ensure they are completed correctly. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of witness on a release of information form in one of seven client records.
Client # 5 was admitted on May 19, 2022 and was active at the time of the inspection. A release of information form for a government agency was signed by the client on May 19, 2022 but was missing a witness signature and date.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The counselors will be required to review their charts upon being assigned a client to ensure the admission paper work was completed correctly. The clinical director will review charts and review all consents to ensure they are completed correctly. |
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.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which includes the reason for termination, in one of one applicable client records.
Client # 1 was admitted on April 21, 2022 and was administratively discharged on May 11, 2022. There was no documentation in the record indicating the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will give all clients administratively discharged notice as to what reason they are being discharged and place a copy of the notice in the client chart and the clinical director will review the chart to ensure the proper paperwork is in the client chart before the chart is closed. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete record of service in three of seven client records.
Client #5 - was admitted on May 19, 2022 and was still active at the time of the inspection. The record of service did not include any entries after May 25, 2022. Progress notes were documented for group sessions on May 26, 27, 28, 29, 30, 31 and June 1, 2022, and a progress note was documented for an individual session on May 21, 2022. Sessions occurring after May 25 are not documented on the record of service.
Client #6 - was admitted on May 16, 2022 and was still active at the time of the inspection.
The record of service did not include entries for group sessions on May 26, 27, 28, 29, 30, 31 and June 1, 2022. Progress notes were documented for group sessions on those days, but the group sessions occurring after May 25 are not documented on the record of service.
Client #7 - was admitted on May 23, 2022 and was still active at the time of the inspection.
The record of service did not include entries for group sessions on May 26, 27, 28, 29, 30, 31 and June 1, 2022. Progress notes were documented for group sessions on those days, but the group sessions occurring after May 25 are not documented on the record of service.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client records and client charts will be updated daily on weekdays and earliest point possible after a weekend break. Counselors will review charts to ensure that and filing and all groups are documented in the record of service file. The clinical director will oversee the counselors work to ensure the charts are up to standard. |