INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from August 27-28, 2013, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Little Creek Lodge, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based upon the review of supervision notes, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisor for the first 6 months of employment in that position.
The findings include:
The facility employed one clinical supervisor, employee # 2, at the time of inspection. Employee # 2 was initially hired by the project on March 21, 2012, but was not employed as the drug and alcohol clinical director until November 28, 2012. The facility failed to provide documentation of monthly meetings between the clinical director and his supervisor for the time frame of November 28, 2012 to May 28, 2013.
The findings were confirmed by the Clinical Director during the review of supervision notes.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 704.6
The Project Director will hold supervision meetings with the Clinical Director starting September 2013 and continue to hold these meetings for the next six (6) months,and be completed no later than 2/15/14 Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on the physical plant inspection, the facility failed to maintain all structures on the grounds so as to be free from any danger to safety.
The findings include:
The physical plant inspection was conducted on August 28 2013, from approximately 8:30 AM to 9:00 AM.
The facility maintained a volleyball court and walking track that was accessed via a wooden plank bridge. The bridge spanned a dry creek bed and the drop-off in the middle of the bridge was greater than 24 inches on both sides. However, the facility failed to maintain well secured handrails on both sides of the bridge, which presented a danger to safety. There were no handrails affixed to the bridge as of August 28, 2013.
The findings were confirmed by the Project Director during the physical plant inspection.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 705.2
On 09/13/13 Railings were install on bridge crossing over dry creek bed to the recreation field and photos will be forwarded to DDAP. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based upon the review of the facility's freezer logs, the facility failed to maintain frozen food at or below 0 degrees Fahrenheit in three of three freezers.
The findings include:
The facility's freezer logs for the time frame of July 30, 2013 to August 27, 2013, were reviewed on August 28, 2013. The facility failed to maintain frozen food at or below 0 degrees Fahrenheit at all times in freezers # 1, 2 and 3 from July 30, 2013 to August 27, 2013.
The findings were confirmed by the Project Director during the physical plant inspection.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 705.7
On 8/29/13 Chef adjusted all freezers temperatures to be held at 0 degrees or below.
To ensure that this does not recur, the Chef will monitor freezer temperatures and record these in log book, ensuring that freezers remain at 0 degrees or below. Clinical Director will ensure going forward that the temperatures are maintained by reviewing log book weekly and if deficiency is found to have freezers repaired or replaced as needed. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based upon a review of the facility's fire drill log, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
The facility's fire drill log for the time frame of August 2012 to July 2013 was reviewed on August 28, 2013. The facility failed to conduct a fire drill during sleeping hours from October 2012 to July 2013.
The findings were confirmed by the Clinical Director during the review of the fire drill log.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 705.10
Clinical Director will ensure that unannounced fire drills will occur and be documented in the fire drill log at least every six months during sleeping hours.
To ensure that this does not recur, the Clinical Director will review fire drill log book monthly to ensure fire drill log has a fire drill during sleeping hours every six months. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations.
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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 upon the review of employee records and administrative documentation, the project failed to demonstrate its efforts toward informing staff of their employee rights in five of five employee records reviewed.
The findings include:
Five employee records were reviewed on August 27, 2013, for notification of employee rights. The facility failed to demonstrate that employees # 2, 3, 4, 5 and 6 were informed of their employee rights prior to the date of inspection.
Employee # 2 was hired by the drug and alcohol project on November 28, 2012. The project was unable demonstrate that employee # 2 was informed of their employee rights prior to the date of inspection.
Employee # 3 was hired by the drug and alcohol project on November 28, 2012. The project was unable demonstrate that employee # 3 was informed of their employee rights prior to the date of inspection.
Employee # 4 was hired by the drug and alcohol project on November 28, 2012. The project was unable demonstrate that employee # 4 was informed of their employee rights prior to the date of inspection.
Employee # 5 was hired by the drug and alcohol project on July 15, 2013. The project was unable demonstrate that employee # 5 was informed of their employee rights prior to the date of inspection.
Employee # 6 was hired by the drug and alcohol project on May 2, 2013. The project was unable demonstrate that employee # 6 was informed of their employee rights prior to the date of inspection.
The findings were confirmed by the project's CFO during the employee record review.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 709.26(e)
CFO and Project director developed Employee rights policy and acknowledgement form which was shown to inspector at time of inspection, all current employees were met with and employee rights policy was explained and all current employee's signed acknowledgement form which was then placed in employee personal file.
To ensure that this does not recur, the CFO will ensure that upon hire employee rights policy will be explained and employees will sign acknowledgement form which will be placed in their personal file. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based upon the review of the facility's policy and procedure manual, an interview with facility staff and the review of administrative documentation, the facility failed to follow its own policy regarding the administration of client medication. In addition, the facility failed to conduct inspections of the drug storage area on a quarterly basis.
The findings include:
The facility's medication policy was reviewed on August 28, 2013, and included the following language:
"Section 709.32 Medication Policies:
c)
1) Little Creek does not administer drugs to any client. All medications are stored and monitored by the facility, all medications are self-administered by the clients."
As a part of the licensing inspection, the Licensing Specialist conducted interviews with facility staff regarding the administration of client medications. During the interview, the Clinical Director confirmed that there were four active clients who received medications on at least a weekly basis. A Drug and Alcohol Residential Worker stated that the facility's practice is for a Drug and Alcohol Residential Worker to fill a 'Sunday through Saturday' daily pill container with the clients' medications. He stated that at medication times the clients are given their pill containers and are monitored taking their medications. The Drug and Alcohol Residential Worker also confirmed that clients themselves do not place their medications in the weekly medication containers. Therefore, the facility violated its own policy on administration of medication as staff members who were not pharmacists or licensed medical employees removed client medications from the medication bottles and placed them in the weekly pill containers.
In addition, the facility did not provide documentation of quarterly inspections of the drug storage area from November 28, 2012 to August 27, 2013.
The findings were confirmed by the facility's Clinical Director at the conclusion of the staff interview.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 709.32
Project Director and Clinical Director developed and addendum to the policy and procedure manual regarding administration of client medication.
As of 8/29/13, all clients who are on medications will refill their weekly medication packs personally while being observed by clinical staff.
Also Clinical Director will perform quarterly inspection of drug storage area and sign off on inspection log sheet.
To ensure that this does not recur, the Clinical Director will observe clinical staff maintaining policy on administration of client medications monthly, and maintain quarterly inspection sign off sheet.. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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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 upon the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two client records.
The findings include:
Two client records for clients who were involuntarily discharged from the project were reviewed on August 28, 2013. The facility failed to notify clients # 7 and 8, in writing, of the decision to terminate their treatment at the project.
Client # 7 was admitted on January 19, 2013, and was involuntarily discharged from the project on March 17, 2013. The record did not include written documentation of the project's decision to involuntarily terminate the client's treatment at the project.
Client # 8 was admitted on May 24, 2013, and was involuntarily discharged from the project on July 14, 2013. The record did not include written documentation of the project's decision to involuntarily terminate the client's treatment at the project.
The Clinical Director confirmed the findings during the client record review.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 709.33
Clinical Director had meeting with all clinical staff and reviewed intent to involuntarily discharge from treatment form and trained staff in proper usage and completion of form. All staff were educated on proper procedures regarding placement of form in client chart and giving client copy of form upon notification of intent to discharge.
To ensure that this does not recur, the Clinical Director will make readily available to all clinical staff the Intent to involuntarily discharge forms in a general location in staff office. Clinical Director will also review client chart prior to discharge to ensure form is in chart and completed properly. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon the review of client records, the facility failed to document proposed type of support services on individual treatment plans contained in six of ten client records.
The findings include:
Ten client records requiring documentation of proposed type of support services on the individual treatment plan were reviewed on August 28, 2013. The facility failed to document proposed type of support services on treatment plans contained in client records # 1, 4, 5, 6, 8 and 9.
The findings were confirmed by the Clinical Director during the client record review.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 709.52(a)
Clinical Director met with counselors in training and reviewed development of treatment plans with clients and how to document proper support services being offered to clients.
To ensure that this does not recur, the Clinical Director will review charts monthly to ensure that support services are document in treatment plans. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based upon the review of client records, the facility failed to document a treatment plan update in one of ten client records. In addition, the facility failed to ensure that a treatment plan update was completed as per the date listed on the update in one of ten client records.
The findings include:
Ten client records requiring documentation of treatment plan updates were reviewed on August 28, 2013. The facility failed to document a treatment plan update in client record # 3 and failed to ensure that a treatment plan update reflected the accurate date of completion in client record # 5.
Client # 3 was admitted on June 21, 2013 and was still an active client as of the date of inspection. The record contained an individual treatment plan that was completed on June 21, 2013 and a treatment plan update that was completed on July 21, 2013. The record did not include documentation of a treatment plan update that was due on or by August 20, 2013.
Client # 5 was admitted on July 5, 2013 and was still an active client as of the date of inspection. The record contained an individual treatment plan that was completed on July 5, 2013 and a treatment plan update that was dated August 5, 2013. As of August 28, 2013, the record also included a treatment plan update that was dated September 5, 2013. The facility failed to ensure that the treatment plan update reflected the accurate date of completion.
The findings were confirmed with the Clinical Director during the client record review.
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Plan of Correction
Little Creek Lodge has created the following Plan of Correction in response to deficiencies found during an on-site licensure renewal inspection conducted from August 27-28, 2013 in the application of Regulation 709.52(b)
Clinical Director met with counselors in training and reviewed the need for timely treatment plan updates.
To ensure that this does not recur, the Clinical Director will review charts monthly to ensure that treatment plan updates are done as planned on treatment plans. Also Clinical Director will sign off on case consults regarding treatment plan updates. Therefore meeting DDAP requirements as stated in the DDAP Licensure regulations
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