INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted June 4-5, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Huntington Creek Recovery Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
The facility failed to store all trash in covered containers that prevent the penetration of insect and rodents, and remove it, at least once a week.During a complaint investigation on June 5, 2024, all of the dumpsters were observed to have their lids open and the dumpster by the male adolescent house was overflowing with cardboard boxes piled up on the ground beside the dumpster.
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Plan of Correction
The cardboard boxes were broken up and placed in the dumpster. The dumpster lids have been closed. The waste management company could not remove the garbage due to staff vehicles blocking the area on garbage night. Facility leadership have instructed staff to not block the dumpsters with their vehicles. Weekly leadership rounds will ensure compliance going forward. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of a client chart during a complaint investigation, the facility failed to submit an unusual incident report for a physical assault by a client.On May 13, 2024 a client was physically assaulted by another client. An unusual incident report was not provided as required.
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Plan of Correction
The unusual incident report was submitted on 07/03/24.
The Director of Q&PI spoke with the Risk Management Assistant who is responsible for entering unusual incidents on 06/05/24.
The unusual incident reporting process was reviewed with leadership staff who provided instruction to their teams. The Director of Q&PI will continue to provide supervision and monitoring with the Risk Management Assistant regarding this process. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of a client chart during a complaint investigation, the facility failed to submit an unusual incident report when the police were on the premises.On May 14, 2024 the State Police were at the facility to interview a client regarding an alleged assault. An unusual incident report was not provided as required.
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Plan of Correction
The unusual incident report was submitted on 07/03/24.
The Director of Q&PI spoke with the Risk Management Assistant who is responsible for entering unusual incidents on 06/05/24.
Facility staff thought they needed to only notify the Risk Management Assistant of police on-site for incidents in which the facility initiated the call. The unusual incident reporting process was reviewed with leadership staff who provided instruction to their teams. The Director of Q&PI will continue to provide supervision and monitoring with the Risk Management Assistant regarding this process. The Director of Q&PI will continue to monitor this for compliance. |