INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2-3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Huntington Creek 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of qualifications for the project director.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director and the facility director obtained documentation of qualifications for the project director on 1/13/2020. This documentation included copies of the college degree and Social Work License. These documents have been included in the project director's personnel file. The HR director will continue to monitor and review personnel charts to ensure all required documents are accounted for. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers 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 document the instruction of all staff in the use of the fire extinguishers upon employment. Employee # 1 was hired on December 16, 2019, but the employee record did not include documentation of fire extinguisher instruction.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR Director has documented Employee #1's "instruction in the use of fire extinguisher" training as of 1/6/2020. This has been added to the employee's personnel file. HR Director will continue to monitor personnel files to ensure that all required documentation are in the files. Quality Assurance will check personnel files quarterly to ensure compliance. Facility was in full compliance on 1/06/2020. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill records, the facility failed to document the exit route used and whether the fire alarm or smoke detector was operative.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Risk Manager has revised facility's standard "Fire Drill Forms" to include a space that calls for "exit used" on each form. This revised form will be used by the facility in all future fire drills. The Risk manager has also added a box to document whether or not the alarm was operable. This will be monitored monthly by the risk manager, and quarterly by Quality Assurance Manager. Facility was in full compliance on 2/24/2020. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the policy and procedures manual, the facility failed to document personnel policy and procedures that include the utilization of volunteers.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Human Resource Director have reached out to the governing body and located the written personnel policy on "Utilization of Volunteers". This policy was added to the policy and procedure manual. Facility was in full compliance as of 1/13/2020. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of the policy and procedures manual, the facility failed to document personnel policy and procedures that include rules of conduct.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Human Resource Director have reached out to the governing body and located the written personnel policy on "Rules of Conduct". This policy was added to the policy and procedure manual. Facility was in full compliance as of 1/13/2020. |
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 document informed and voluntary consent from the client for the disclosure of information in three out of ten client records.Client # 1 was admitted on December 28, 2019 and was still active at the time of the inspection. A fax was sent to a probation officer on January 2, 2020 without a proper informed and voluntary consent to disclose form signed by the client prior to the disclosure.Client # 5 was admitted on December 10, 2019 and was still active at the time of the inspection. A fax was sent to a probation officer on December 12, 2019, a phone call to probation officer on December 12, 2019, and a fax sent to a disability company on December 23 and 31, 2019. A disclosure log was provided to a probation officer on December 13 and 24, 2019 and January 3, 2020. There was not an informed and voluntary consent to disclose form signed by the client prior to the disclosure.Client # 9 was admitted on June 17, 2019 and discharged on July 15, 2019. Client information was disclosed to a funding source without a proper informed and voluntary consent to disclose form signed by the client prior to the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The specific course of action for this citation includes: changes to the EMR to better identify contacts that have signed releases, implementing new check off system that allows for staff to ensure proper consents are signed prior to the release of information, and, training of staff of the new system as well as the importance of obtaining proper consent prior to the release of information. The facility director has developed the training on the new system and the importance of proper consent. The therapists, and admissions personnel will be responsible for checking to ensure proper consents are in place prior to the release of information. QA personnel will monitor charts weekly to ensure continued compliance. Client #1 was still active and a consent form was signed for his probation officer on 2/11/2020. Client #5 was still active and a consent form was signed for his probation officer and his disability chart on 2/13/2020. Client #9 was not active at the time. Therefore no corrective action was taken. All of the above noted actions were complete and the facility was in full compliance as of 2/6/2020. |
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 keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in eight out of ten client records.Client # 1 was admitted on December 28, 2019 and was still active at the time of the inspection. A consent to release form signed and dated December 28, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records.Client # 2 was admitted on December 28, 2019 and was still active at the time of the inspection. A consent to release form signed and dated December 28, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records.Client # 3 was admitted on December 31, 2019 and was still active at the time of the inspection. A consent to release form signed and dated December 31, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records.Client # 4 was admitted on December 3, 2019 and was still active at the time of the inspection. A consent to release form signed and dated December 3, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records.Client # 5 was admitted on December 10, 2019 and was still active at the time of the inspection. A consent to release form signed and dated December 10, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records.Client # 6 was admitted on December 6, 2019 and was still active at the time of the inspection. A consent to release form signed and dated December 6, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records.Client # 7 was admitted on December 23, 2019 and was still active at the time of the inspection. A consent to release form signed and dated December 23, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records. Also, a consent to release form signed December 23, 2019 to the client's father only allowed for the release of medication records, but the father signed all of the client ' s orientation and intake forms. Client # 10 was admitted on October 5, 2019 and was discharged on November 4, 2019. A consent to release form signed and dated October 5, 2019 to a funding source allowed for the release of psychiatric evaluation, history and physical, practitioner orders, practitioner progress, lab reports, immunization records, and medication records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The specific course of action to be taken for this citation is that the staff, including all admissions staff, counselors, nurses, and anyone else responsible for maintaining the client record, were trained on the appropriate use of consent forms particularly, understanding the restrictions of 255.5. During the facility's annual staff training and development, the facility director re-trained all staff on the use of consents and particularly discussed 255.5 to include what type of information is allowed to be released to Government Agencies, Insurance companies, employers, probation officers, CYS, and judges. QA personnel will monitor charts weekly to ensure the proper consents are being utilized by all staff. This report will be monitored by the facility director. A cheat sheet was provided to all staff responsible for maintaining the client record so the staff can better understand what type of information can be released in various situations. The admissions staff met with Client #1, Client #2, Client Number 3, Client #4, Client #5, Client #6, Client #7, and Client #10 on 1/7/2020, and explained the errors in the initial consent forms used. those consent forms were replaced as of 1/7/2020 The facility was in full compliance with this standard as of 2/6/2020 after annual staff training. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consents will expire. Client # 1 was admitted on December 28, 2019 and was still active at the time of the inspection. A consent to release form to a funding source did not state when the consent was to expire.Client # 2 was admitted on December 28, 2019 and was still active at the time of the inspection. A consent to release form to a funding source and the wife did not state when the consent was to expire.Client # 3 was admitted on December 31, 2019 and was still active at the time of the inspection. A consent to release form to a funding source and to the client ' s the wife did not state when the consent was to expire.Client # 4 was admitted on December 3, 2019 and was still active at the time of the inspection. A consent to release form to a funding source and the mother did not state when the consent was to expire.Client # 5 was admitted on December 10, 2019 and was still active at the time of the inspection. A consent to release form to a funding source and to the client ' s the mother did not state when the consent was to expire.Client # 6 was admitted on December 6, 2019 and was still active at the time of the inspection. A consent to release form to a funding source and the client ' s wife did not state when the consent was to expire.Client # 7 was admitted on December 23, 2019 and was still active at the time of the inspection. A consent to release form to a funding source and to the client ' s the father did not state when the consent was to expire.Client # 10 was admitted on October 5, 2019 and was discharged on November 4, 2019. A consent to release form to a funding source and the client ' s aunt did not state when the consent was to expire.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The specific action that needed to be taken for this citation was that the hard copy release forms our facility was using during admissions, needed to be revised to include an expiration date. The default expiration date on the new forms is 6 months after the initial release is signed. These forms were revised and replaced by admissions personnel.The admissions department had a meeting with active clients on 1/7/2020 to discuss issues with the current release forms we had in the chart. During these meetings with the active clients, the forms were re-signed and replaced in the chart. The client who were still active when the admission personal changed the releases were #': 1, 2, 3, 5, and 7. The facility was in full compliance as of 1/7/2020. |
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 was offered to the client in eight out of ten records. In client records # 1, 2, 3, 4, 5, 6, 7 and 10, all consent to release forms did not document whether a copy was offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The specific action that needed to be taken for this citation was that the hard copy release forms our facility was using during admissions, needed to be revised to include check boxes that provide the client an opportunity to request a copy of the release or decline a copy of the release. After admissions personnel corrected the forms on 1/6/2020, admissions staff met with current client (1, 2, 3, 5, and 7) and replaced the consent forms in their charts.These forms were revised and replaced by admissions personnel. Quality Assurance personnel monitors all clients charts weekly. During the weekly chart monitoring, QA will ensure clients are checking the box about whether they would like a copy of their consent forms. This report is submitted to the facility director and will be reviewed weekly as well. The facility was in full compliance as of 1/7/2020. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the policy and procedures manual, the project failed to develop and implement procedures to respond to selling or use of illicit drugs on the premises. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The specific action to be taken for this citation was to develop and implement a policy and procedures to respond to "selling or use of illicit drugs on premises". The facility director, along with quality assurance manager located and developed a policy and procedures for the above noted unusual incident. This was approved by the governing body and added to the policy and procedure manual on 1/3/2020. During the annual staff training and development, the facility director informed staff of the new policy and procedures related to unusual incidents. The facility was in full compliance as of 2/6/2020. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the policy and procedures manual, the project failed to develop and implement procedures to respond to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The specific action to be taken for this citation was to develop and implement a policy and procedures to respond to "Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services". The facility director, along with quality assurance manager located and developed a policy and procedures for the above noted unusual incident. This was approved by the governing body and added to the policy and procedure manual on 1/3/2020. During the annual staff training and development, the facility director informed staff of the new policy and procedures related to unusual incidents. The facility was in full compliance as of 1/6/2020. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the policy and procedures manual, the project failed to develop and implement procedures to respond to theft, burglary, break-in or similar incident at the facility. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The specific action to be taken for this citation was to develop and implement a policy and procedures to respond to "Theft, burglary, break-in or similar incident at the facility". The facility director, along with quality assurance manager located and developed a policy and procedures for the above noted unusual incident. This was approved by the governing body and added to the policy and procedure manual on 1/3/2020. During the annual staff training and development, the facility director informed staff of the new policy and procedures related to unusual incidents. The facility was in full compliance as of 2/6/2020. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the policy and procedures manual, the project failed to develop and implement procedures to respond to fire or structural damage to the facility. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The specific action to be taken for this citation was to develop and implement a policy and procedures to respond to "Fire or structural damage to the facility". The facility director, along with quality assurance manager located and developed a policy and procedures for the above noted unusual incident. This was approved by the governing body and added to the policy and procedure manual on 1/3/2020. During the annual staff training and development, the facility director informed staff of the new policy and procedures related to unusual incidents. The facility was in full compliance as of 2/6/2020. |
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 on a review of client records, the facility failed to document individual treatment and rehabilitation plans developed with the client in five out of six records. Client # 4 was admitted on December 3, 2019 and was still active at the time of the inspection. The comprehensive treatment plan dated December 3, 2019 was not signed by the client. Client # 5 was admitted on December 10, 2019 and was still active at the time of the inspection. The comprehensive treatment dated December 11, 2019 was not signed by the client. Client # 6 was admitted on December 6, 2019 and was still active at the time of the inspection. The comprehensive treatment plan dated December 6, 2019 was not signed by the client. Client # 7 was admitted on December 23, 2019 and was still active at the time of the inspection. The comprehensive treatment dated December 27, 2019 was not signed by the client. Client # 10 was admitted on October 5, 2019 and was still active at the time of the inspection. The comprehensive treatment plan dated October 7, 2019 was not signed by the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The specific action that needs to be taken to achieve and maintain compliance with this standard is that the facility needs to develop a new procedure for documenting that individual treatment plans have been developed with the client. The clinical director, in conjunction with quality assurance personnel have developed a new system which allows for the client to sign the comprehensive treatment plan upon the implementation date. This new system will be presented to clinical and nursing staff during a training on 2/20/2020. The new system will take effect immediately after the training. Quality assurance personnel will monitor compliance on a weekly basis and submit reports to the clinical director. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records the facility failed to document a discharge summary in one out of three records. Client # 8 was admitted on May 14, 2019 and discharged on May 16, 2019. The record did not include a discharge summary.
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Plan of Correction
The specific action that needed to be taken to be in full compliance with this standard is that a discharge summary needed to be added into client number 8's chart. The counselor for client #8 did enter a discharge summary for this client on 1/15/2020. QA will continue to monitor charts weekly for compliance, and report findings to facility director. The facility was in full compliance with this citation as of 1/15/2020. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three out of three records. The facility ' s policy states follow-up occurs every 30, 60, 90, and 180 days. Client # 8 was admitted on May 14, 2019 and discharged on May 16, 2019, but follow-up was only documented on May 17, 2019. Client # 9 was admitted on June 17, 2019 and discharged on July 15, 2019, but follow-up was only documented on July 18, 2019. Client # 10 was admitted on October 5, 2019 and discharged on November 4, 2019, but the record did not include documentation follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The specific action that needs to be taken to be in compliance with this standard is that the facility needs to have the ability to provide DDAP auditors with access to "sales force" system in which they are able to see documentation of follow-up. During this audit, facility director did not have required access to demonstrate the documentation for the clients noted in this citation. Moving forward, the facility has contacted quality assurance personnel to ensure that auditors will have access to the system in order to see long term follow-up documentation. The facility is in full compliance with this standard as of 1/3/2020. |