INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 15, 2018 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
A personnel record reviewed conducted on March 15, 2018 indicated that the facility failed to ensure that a counselors assistant with a high school diploma counseled clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment. Several client files were reviewed in addition to Counselor #1's personnel record. It was determined from the review of client files that the clinical supervisor was not signing off on all client progress notes or treatment plans being completed by this counselor.
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Plan of Correction
Graniteville will be more diligent and thorough in our hiring process to ensure we remain in compliance. CFO will check resume and credentials for all new hires. CFO will also check resume prior to hire to ensure it meets DDAP requirements of education and experience. Graniteville no longer has that counselor assistant on our employee roster. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
An administrative review conducted on March 15, 2018 indicated that the facility failed to ensure that it complied with the client/counselor ratios during primary care hours.On the day of the onsite review the facility's census was sixteen clients. All of these clients were being treated by the clinical supervisor.
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Plan of Correction
Graniteville is now in compliance with client/counselor ratio. Graniteville now keeps an active posting for counselors in the event some are terminated or leave for immediately replacement in order to remain in compliance. Facility Director monitors all staff and will ensure we remain in compliance with client/counselor ratio. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to keep the exterior grounds safe and in good repair.The concrete ramp that serves as access to the primary entrance of the facility was cracked and chipped away in two separate areas which presented a tripping hazard.This is a repeat citation from the previous licensing visit which occurred on October 19, 2017.In addition, the storage closet door ,across from the TV Room near Room 22, was off it's hinges. There was also snow and ice observed on the facility entrance ramp and on the steps out of the building through the exit door near rooms 11 and 1. Finally, it was observed that the couch in the waiting room had an armrest that was broken.
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Plan of Correction
Front exterior walk way crack was repaired during previous inspection. Since then, more damage has been apparent. All cracks have now been repaired as of 5/5/2018 when warmer weather occurred to repair cement.
Closet door has been repaired as of 3/16/2018.
We have also hired a snow removal service that will come and remove all snow during the winter months. 3/19/2018
Couch in the waiting area has been removed as of 3/18/2018
In order to remain in compliance, Graniteville will have techs do daily checks of the facility to ensure there are no damages that need repair. Resident Manager will ensure we remain in compliance with our physical plant standards.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to provide privacy in showers by partitions, doors or curtains. The first/front bathroom across from Room #4 had a shower which did not have a shower curtain.
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Plan of Correction
Graniteville will have our techs on each shift checking the facility to ensure all basic amenities and needs of our clients are available. Techs will report any and all information to Resident Manager who will ensure we remain in compliance.
Graniteville has placed all shower curtains in all bathrooms. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.The back/rear bathroom across from Room #4 had mold around the shower stall and around the window. Additionally, the cover for the exhaust fan was detached from the fan unit and was hanging from the ceiling.
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Plan of Correction
Mold has been removed and exhaust has been repaired. Mold appeared due to the exhaust not working properly. We have tasked our techs on each shift to ensure a sanitary and clean environment for our clients by checking rooms and bathrooms of facility. Techs will bring it to their supervisors attention should anything not be in proper conditions for immediate repair. Resident Manager will inform Facility Director to make arrangements for repairs to be corrected. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to ensure that storage areas for food are free of food particles, dust and dirt.It was observed during the physical plant inspection that Room 11 was being used to store food and bags of client clothing.
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Plan of Correction
Graniteville has separated items and now has designated storage areas for food and client belongings. Resident Manager will conduct monthly storage room inspections, at minimum, to ensure we remain in compliance. |
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 on a physical plant inspection conducted on March 15, 2018, the facility failed to keep cold food at or below 40F.The refrigerator in the kitchen adjacent to the dinning/meeting room was not functioning properly. The inside temperature of this appliance was 54F. The refrigerator was being used to store food.
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Plan of Correction
Graniteville tasks our techs with checking temperatures nightly and recording on temperature logs to ensure no food items are being stored in refrigerators that are not at proper functioning temperatures. We have removed and discarded any food that was placed in a refrigerator that did not have the correct temperature to store food.
Resident Manager checks logs every morning to ensure techs are logging temperatures. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to store all food items off the floor.It was observed during the physical plant inspection that Room 11 was being used to store food, some of which was on the floor.
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Plan of Correction
Graniteville has lifted all food items off the floor and continues to keep food items placed in designated storage areas. Monthly room inspections conducted by Resident Manager helps ensure we remain in compliance. |
705.9 (2) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(2) Require that pets housed in the residential facility are cared for in a safe and sanitary manner.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to require that pets housed in the residential facility are cared for in a safe and sanitary manner.It was observed during the physical plant inspection that cat food was being kept in the kitchen. Facility staff reported that clients were feeding a stray cat.
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Plan of Correction
Graniteville called appropriate agency to remove cat from premises. Cat food was discarded 3/15/2018 and cat was removed on 3/19/2018. Techs ensure there are no stray cats or any other animals being fed or taken care of during their daily perimeter checks of the facility. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to ensure that exits from rooms and from the residential facility are unobstructed. It was observed during the physical plant inspection that the exit door closest to Rooms 1 and 11 was not functioning properly. This exit door has a locking mechanism that is malfunctioning which may prevent this door from being unlocked.
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Plan of Correction
Door has been repaired and able to exit in the event of an emergency. Repair took place on 3/22/2018. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.It was observed during the physical plant inspection that the exit door near Rooms 18 & 19 lead unto a small stair case that was damaged and unsafe for use.
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Plan of Correction
Exit door has been blocked off and signs pointing to exit have been covered or removed to ensure no one tries to use as an exit. Facility Director will ensure the door remains blocked to safeguard all those residing, employed, or visiting Graniteville. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on March 15, 2018, the facility failed to secure hard copy client records within locked storage containers.During the physical plant inspection, unsecured confidential client information was observed in Room 22 on the mantle and desk.
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Plan of Correction
Confidentiality is very important to Graniteville. Confidentiality trainings are completed during orientation. CFO does random walk throughs of offices to ensure no confidential client information is being left in plain site or not stored in locked room in locked filing cabinet. |
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
A review of client files conducted on March 15, 2018 indicated that the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.While onsite, it was observed by DDAP staff that a staff member from a treatment provider walked into the facility and onto a client common area. The facility did not have a consent in the client records for this treatment provider. The facility also did not have a qualified service organization agreement with this provider.
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Plan of Correction
Graniteville now has a QSOA with all agencies that come in often to provide services to our clients. Our Director of Admissions makes sure to collect all QSOA's upon initial visit to facility. |