INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and complaint investigation conducted on March 31, 2021 and April 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and a discussion with the executive director, the facility failed to employ a project director responsible for the overall management of the project and staff.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection conducted on November 24, 2020.
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Plan of Correction
As of April 13, 2021, the facility has appropriately identified and secured a qualified candidate for the Facility Director position responsible for the overall management of the project and staff along with clinical supervision.
In the event of position vacancy, the Executive Director is responsible for finding and securing a qualified candidate in a timely manner. |
704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and a discussion with the executive director, the facility failed to have a clinical supervisor on staff or facility director who has direct responsibility for clinical services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of April 13, 2021, the facility has appropriately identified and secured a qualified candidate for the Facility Director position responsible for the overall management of the project and staff along with clinical supervision.
In the event of position vacancy, the Executive Director is responsible for finding and securing a qualified candidate in a timely manner. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of documents provided and a discussion with the executive director, the facility failed to complete an assessment of staff training needs.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection conducted on November 24, 2020.
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Plan of Correction
Facility Director has developed and identified baseline staff assessment training needs based on immediate educational/training needs, current treatment modalities/ best practice procedures, and mandated qualifications and requirements and will continue on a yearly basis.
Facility Director has developed a standardized assessment of employees training needs based on peer evaluations, self-assessments, and yearly job performance reports. Staff assessments and training needs shall be reviewed semi-annually. Responsibility of Facility Director. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of documents provided and a discussion with the executive director, the facility failed to complete an overall training plan for staff development needs.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection conducted on November 24, 2020.
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Plan of Correction
Facility Director has developed and identified staff assessment training needs based on immediate educational/training needs, current treatment modalities/ best practice procedures, and mandated qualifications and requirements and will continue on a yearly basis.
Facility Director has developed a standardized assessment of employees training needs based on peer evaluations, self-assessments, and yearly job performance reports. Staff assessments and training needs shall be reviewed semi-annually. Responsibility of Facility Director. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and a discussion with the executive director, the facility failed to ensure staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
The executive vice director was hired in August 2017 and was current in that position. There is no documentation of the completion of a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has developed and identified baseline staff assessment training needs based on immediate educational/training needs, current treatment modalities/ best practice procedures, and mandated qualifications and requirements and will continue on a yearly basis.
Trainings have been identified to satisfy any individual training deficiencies subject to current training availability. Individuals are personally responsible for completing trainings. Earliest training opportunity reflected in correction date.
Facility Director has developed a standardized assessment of employees training needs based on peer evaluations, self-assessments, and yearly job performance reports. Staff assessments and training needs shall be reviewed semi-annually. Responsibility of Facility Director. |
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
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and a discussion with the executive director, the facility failed to comply with the client/staff and client/counselor ratios during primary care hours. The facility has an exception allowing a client counselor ratio for 1/10. At the time of the inspection the facility only employed one counselor and had a census of sixteen clients resulting in a ratio of 1/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of April 2021 all clinical ratios have been appropriately satisfied. In the event of future clinical staffing ratio disruption, the facility will temporarily defer admissions until ratios concerns are resolved. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to follow their written plan for the coordination of client treatment and rehabilitation services which includes written procedures for the management of treatment/rehabilitation services for clients. The facility ' s written plan for providing individual counseling sessions listed two sessions a week. Based on the review of six client records the facility was only providing one individual session per week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has reviewed and updated treatment management policies and procedures to ensure quality clinical care and to further ensure policy compliance and consistency.
Facility Director will continue ongoing monitoring of treatment procedures and annual review of program policies. |
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 six client records the facility failed to ensure informed and voluntary consent from the client for the disclosure of information stayed within the limits of 255.5 in four records reviewed.
Client #1 was admitted on December 1, 2020 and was still active at the time of the inspection. A consent to release to employer was signed and dated on January 12, 2021 that allowed for the release of employment info and progress in treatment.
Client # 2 was admitted on December 22, 2020 and was still active at the time of the inspection. A consent to release form to a county agency was signed and dated on January 7, 2021 that allowed for the release of psychological assessment, psychiatric history and assessment, results of physical, medical history, biopsychosocial, labs , employment, legal status, family information, aftercare, discharge planning and discharge summary.
Client #3 was admitted on February 5, 2021 and was discharged on March 12, 2021. A consent to release form to a county agency was signed and dated on February 5, 2021 that allowed for the release of psychological assessment, psychiatric history and assessment, results of physical, medical history, biopsychosocial, labs , employment, legal status, family information, aftercare, discharge planning and discharge summary.
Client #6 was admitted on February 24, 201 and was still active at the time of the inspection. A consent to release to a probation officer was signed and dated on February 25, 2021 that allowed for the release of psychological assessment, psychiatric history and assessment, results of physical, medical history, biopsychosocial, labs , employment, legal status, family information, aftercare, discharge planning and discharge summary.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from an inspection conducted on November 24, 2020.
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Plan of Correction
All confidentiality release templates have been reviewed and revised in accordance with confidentiality guidelines. Additionally, all clinical staff have been individually coached to review and ensure ongoing confidentiality compliance.
During monthly chart review, Facility Director will ensure consents are appropriately filled and correct any deficiencies. Existing non-compliant consents will be replaced accordingly. Ongoing responsibility of the Facility Director. |
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 ensure that all clients were offered a copy of their consent to release in two of six client records reviewed.
Client #3 was admitted on February 5, 2021 and was discharged on March 12, 2021. A consent to release form to an outside source was signed and dated on March 9, 2021 that did not document if the client refused or accepted a copy of the consent.
Client #6 was admitted on February 24, 201 and was still active at the time of the inspection. One consent to release to a probation officer, one to a treatment facility and one to a dental office was signed and dated on February 25, 2021 that did not document if the client refused or accepted a copy of the consent.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All confidentiality release templates have been reviewed and revised in accordance with confidentiality guidelines. Additionally, all clinical staff have been individually coached to review and ensure ongoing confidentiality compliance.
Responsibility of Facility Director.
During monthly chart review, Facility Director will ensure consents are appropriately filled and correct any deficiencies. Existing non-compliant consents will be replaced or updated accordingly. Ongoing responsibility of the Facility Director. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of six client records, the facility failed to include documentation of a physical examination in all records reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from inspections conducted on November 24, 2020, June 23, 2020 and October 4, 2019.
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Plan of Correction
During weekly care team meeting, Facility Director will review most recent admissions to ensure physical examination documentation has been received.
The scheduler will continue to schedule physical exams within 7 days and provide forms to the client to be completed by the physician.
Consents to communicate with the physician's office are documented upon admission. In the event of non-return of physical examination record, scheduler will attempt to contact physician's office to obtain a copy. If attempts are unsuccessful, scheduler will document the completion date of the initial exam but will also reschedule client for a secondary physical for form completion. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of six client records, the facility failed to develop individual treatment and rehabilitation plans with the client that included written documentation to include the type of treatment and rehabilitation services in all six records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During Facility Director clinical chart review, Facility Director will ensure treatment plans reflect all required documentation.
During monthly chart review, Facility Director will ensure treatment plans are completed satisfactorily and advise the primary counselor to correct any deficiencies. Ongoing responsibility of the Facility Director.
Facility Director will annotate existing client plans to include type. |