INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12-13, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Graniteville House of Recovery 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Due to the expiration of the certifications in CPR of several staff members, the facility failed to ensure that it had a sufficient number of staff persons certified in CPR.
The facility is a residential treatment facility that operates 24 hours a day 7 days a week.
The CPR certifications were submitted as part of the presubmission process, and the facility staff were interviewed about the CPR certifications during the on-site inspection.
At the time the presubmission information was sent to the Department through the time of the on-site inspection, the facility did not have CPR coverage on Saturdays and Sundays, or on Mondays through Fridays from 5:00PM to 8:00AM..
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A sufficient amount of staff attended a CPR certification course in August. Facility Director will check all new hires certification and schedule appropriate trainings for those that need in order to remain in compliance with coverage for 24 hours. |
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
The facility failed to ensure that proper food temperatures were maintained in its refrigerators and freezers.
A physical plant inspection of the two kitchen areas was conducted on September 13, 2018.
Refrigerator #1 in Kitchen #1 had a tested temperature of 66 degrees Fahrenheit.
Freezer #2 in Kitchen #1 had a tested temperature of 10 degrees Fahrenheit.
Refrigerator #1 in Kitchen #2 had a tested temperature of 53 degrees Fahrenheit.
Freezer #1 in Kitchen #2 had a tested temperature of 16 degrees Fahrenheit.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Refrigerator #1 in Kitchen #1 had been unplugged and will be removed. No food is currently being stored in there. It will be discarded.
Freezer #2 in Kitchen #1, Refrigerator #1 in Kitchen #2, and Freezer #1 in Kitchen #2 temperatures had all been turned down to reflect compliance. Lead resident tech will ensure compliance. Temperatures are checked daily. If any temperature reflects numbers out of compliance, lead tech will bring to facility directors attention to schedule a repair or replacement. |
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
The facility fire drill records were reviewed as pat of the presubmission process, and reviewed during the on-site inspection. The facility failed to list all of the required information on its fire drill records.
None of the fire drill records included the evacuation routes used during the monthly fire drills.
These findings were reviewed by facility staff as part of the inspection process.
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Plan of Correction
Facility Director has updated our fire drill simulation log to reflect the exit taken during the fire drill. Facility Director will ensure compliance with monthly audits of the fire drill simulation log to ensure all information was included and accurately recorded. |
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
The facility failed to ensure that the signed consents to release information forms contained all of the required information in twop of seven records reviewed.
Client # 2's consent to release information to another treatment provider dated March 28, 2018, did not have a termination date or termination condition.
Client # 2's consent to release information to a pharmacy dated March 28, 2018, did not have a termination date or termination condition.
Client # 4's consent to release information to the therapist of the client's son dated June 13, 2018, did not have a termination date or termination condition, and was missing the witness signature.
Client # 4's consent to release information to the client's attorney dated June 13, 2018, did not have a termination date or termination condition, and was missing the witness signature.
These findings were reviewed with facility staff as part of th inspection process.
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Plan of Correction
All consents had since been updated to reflect compliance. Graniteville now uses one universal consent and has trained all staff on how to properly fill in a consent. What information to include, sign, date, etc. Facility Director will ensure compliance with monthly audits of clinical files. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to ensure that clients received group counseling services with the frequency documented on the clients' individualized treatment plans in three of seven client records reviewed.
Client #1 was admitted for treatment on April 27, 2018, and discharged on July 24, 2018. The client's individualized treatment plan dated April 27, 2018, documents that the client was to received group counseling twice weekly. The client received group counseling only three times in May of 2018, only two times in June of 2018, and only four times in July of 2018.
Client #2 was admitted for treatment on March 27, 2018, and discharged on June 22, 2018. The client's individualized treatment plan dated March 27, 2018, documents that the client was to received group counseling twice weekly. The client received group counseling only four times in April of 2018, only one time in May of 2018, and zero times June of 2018.
Client #5 was admitted for treatment on March 6, 2018, and discharged on June 12, 2018. The client's individualized treatment plan dated March 7, 2018, documents that the client was to received group counseling twice weekly. The client received group counseling only one time in May of 2018, only zero time in June of 2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Counselors have been trained on how to accurately generate individualized treatment plans. Each client's individual progress and goals should be included in their treatment plan. Plans should not reflect a set standard, but tailored to that individuals treatment needs. Facility Director/Clinical Supervisor will ensure compliance with weekly counselor meetings and monthly chart audits. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to ensure that it documented discharge summaries and/or follow-up information in three of five records reviewed.
A total of five records for discharged clients were reviewed during the on-site inspection.
Client #2 was admitted for treatment on March 27, 2018, and discharged on June 22, 2018. There was no documented follow-up for the client.
Client #4 was admitted for treatment on May 18, 2018, and discharged on July 2, 2018. There was no documented discharge summary for the client.
Client #5 was admitted for treatment on March 6, 2018, and discharged on June 12, 2018. There was no documented discharge summary for the client.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All client files stated have been updated to reflect discharge summaries and follow ups. In addition, all counselors received a guideline for clinical deadlines regarding submission of all clinical information/documentation that also included our follow up policy. Facility Director will ensure compliance with monthly file audits and weekly clinical activity monitoring. |