INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of six personnel records, the facility failed to ensure that one applicable employee who has not functioned for 2 years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision.
Employee #3 was hired on September 14, 2020 as the clinical supervisor and is current in that position. Employee #3 has not functioned for 2 years as a supervisor in the provision of clinical services and at the time of the inspection, had not completed a core curriculum in clinical supervision within six months of hire.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Qualifications for the position of clinical supervisor and lead counselor.: When a person is hired or promoted into a position requiring DDAP training, notification will be made to all concerned that they must complete training within 6 months by the HR Manager. A system of notification for the CEO, Director of HCRC and the Director of Quality will be developed by the Human Resource Manager including setting up automated reminders for all involved and contacting the staff member that requires the training. The staff member who was non-compliant with this regulation was removed from the position and voluntarily resigned. |
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 a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
The rear porch banister at the adolescent ' s residential building was missing posts in a way that could allow individuals to fall off the porch.
These findings were discussed with facility staff during in the inspection process.
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Plan of Correction
On the day of exit from the survey (10/28/2021) the missing spindles were replaced on the porch railing. All spindles are in place at this time. The work has been completed.
Monthly inspections of the property are completed by facilities management. Results, work orders and corrections are noted in the electronic TELS system that is designed for residential care settings. Checking the integrity of all hand rails and structures will be added to the TELS system to assure that this does not happen again. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted October 28, 2021 it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as evidenced by the following:
Ranger room- both the front and side entrance door with windows were not covered.
A Counselor office window was not covered.
Upstairs conference room used as a group room had windows that were not covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Blinds and/or Curtains were added on 10/29/2021 to all locations noted by the surveyor as being deficient. This has been corrected.
Monthly inspections of the property are completed by facilities management. Results, work orders and corrections are noted in the electronic TELS system that is designed for residential care settings. Checking that blinds or curtains are in place and in good repair where counseling session are held will be added to the TELS system to assure that this does not happen again. |
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 fire drills from October 2020 thru September 2021 the facility failed to ensure that the fire drill record included the exit route used for the drills conducted in November 2020, December 2020, January 2021, April 2021, and June 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The fire drill form will be updated to include the route used to evacuated the buildings on premises.
The staff taking on the responsibilities as the Safety Leader will be trained to complete the form correctly.
A description of responsibilities for the Safety Office will be developed. It will outline all duties to be performed. The drill forms and documentation will be reviewed by the Director of Quality or their designee for completeness.
A schedule of fire drills will be developed to ensure compliance with timing of drills so that there is a fire drill every 6 months during sleeping hours.
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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 on a review of fire drills from October 2020 thru September 2021 the facility failed to conduct a sleeping fire drill at least every six months. The last sleeping fire drill documented was completed on December 17, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
A monthly schedule for the year will be established to ensure fire drills are conducted during sleeping hours at least every 6 months. The schedule will be completed and submitted to the Director of Quality for review by the end of December 2021.
The Safety Officer will receive training on the requirements for Fire Drills and documentation of the drills
The Director of Quality or their designee may attend the drills and will review all documentation of the drills to ensure that they meet the standard.
A sleeping hours drill will be conducted no later than December 15th, 2021. |
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 the review of fourteen client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in one client record reviewed prior to the disclosure of information.
Client #8 was admitted on October 1, 2021 and was still an active client at the time of the inspection. There was documentation that a phone call was made to a family member on October 3, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were discussed with facility staff during in the inspection process.
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Plan of Correction
All staff that may be required to communicate with persons or outside agencies will receive refresher training on confidentiality and DDAP Code 255.5. The training will include a competency. All staff will complete the training no later than February of 2022.
The Director of Quality or designee will monitor compliance with completion of consent forms and review 5 random client records a month for 6 months to determine if there have been any further occurrences similar to the one sited. Any occurrences will be reported to the facility Director for follow up actions. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of the facility's system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date, the facility failed to document reasons medication was not given as prescribed in four of seven client records reviewed.
Client #4 was admitted on October 7, 2021 and was discharged on October 11, 2021. There was no documentation for missed doses of medication for the following:
Omeprazole 20mg dose on October 9, 2021
Client #7 was admitted on September 11, 2021 and was discharged on September 17th, 2021. There was no documentation for the missed doses of medication for the following:
Trazodone 50 MG on September 16, 17, 18, 19, 20, 2021
Client #9 was admitted on October 15, 2021 and was still active at the time of the inspection. There was no documentation for missed doses of medication for the following:
Paxil 10mg October 21, 22, 23, 24, 25, 2021
Client #12 was admitted on August 18, 2021 and was discharged on September 15, 2021. There was no documentation for missed doses of medication for the following:
Vitamin C 500MG on September 8, 2021
Client #13 was admitted on August 7, 2021 and discharged on September 4, 2021. There was no documentation listed for missed doses of medication for the following:
Wellbutrin 150mg August 15, 16th, 2021.
These findings were discussed with facility staff during in the inspection process.
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Plan of Correction
The medication administration record has been updated to include a key of reasons why a medication was not given as ordered. Nursing can now efficiently note the reason a medication was not given as prescribed.
The Regional Director of Nursing or her designee will monitor compliance with the new process for 6 months to assure that it is being followed.
Med Refusal Code: #1= "does not like the way it makes me feel" #2= "I don't need it" #3 Other (explain)
Client Name:_____________________________________________ Date of Birth:_________________ Allergies:
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