INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on June 23, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a discussion with facility staff, the project director failed to prepare, annually update and sign a written manual delineating project policy and procedures. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Graniteville is expecting a new Facility Director to begin employment on 7/20/2020. New Facility Director will review, prepare, and update policy and procedure manual within 30 days of start date.
In the absence of a Facility Director during annual review, the Executive Director along with the Executive Vice President will review, prepared, and update policies and procedures. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records, the facility failed to ensure that all releases included purpose of disclosure in two client records. Client #4 was admitted on August 7th 2019 and was still active at the time of the insepction. A consent to release form was signed and dated on August 20th 2019 to an individual that failed to document purpose of the release. Client #4 was admitted on June 12, 2019 and was discharged on August 29, 2019 . A consent to release form was signed and dated on August 15th, 2019 to a lawyer that failed document purpose of the release. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All consents are now reviewed directly by the clients' counselor, who is appropriately trained to develop, review, and sign off on all consents. All day staff have also been enrolled in Confidentiality training for July 2020. Biweekly quality assurance trainings have been implemented to ensure ongoing compliance. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility's medication room, the facility failed to keep documentation of removing outdated drugs for the months of January until July 2019. The facility stated that they had the forms and were documenting but unable to locate at the time of the inspection. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All staff have been trained on proper medication documentation procedures. Outdated medication documentation are maintained in a single secure location. Biweekly quality assurance trainings have been implemented to ensure ongoing compliance. |
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 client's medical records, the facility failed to ensure that documentation of a missed medication was documented in the medical records. The facility also failed to keep documentation of change of dosage/medications which resulted in medication records looking like missed medication. The facility was documenting medication changes on a seperate form that did not specify dates of the change resulting in the medical records presenting as missing medications records. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility has updated its medication documentation procedures and forms to reflect consistent reporting of missed medications and/or details of medication changes. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of physical assault or sexual assault by staff or client. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for physical assault or sexual assault by staff or client. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of selling or use of illicit drugs on the premises. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for the sale or use or illicit drugs on premises. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for significant disruption of services due to disaster such as fire, storm, flood, or other occurrence which closes the facility for more than one day. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures.
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of Theft, burglary, break-in or similar incident at the facilityThese findings were discussed with facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for theft, burglary, break-in, or similar incident at the facility. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of Event at the facility requiring the presence of police, fire or ambulance personnel. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for an event at the facility requiring the presence of police, fire, or ambulance personnel. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures.
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of Fire or structural damage to the facility. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for fires or structural damage to the facility. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the unusual incident policy, the facility failed to develop and implement policies and procedures that address the unusual incident of Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. These findings were discussed with facility staff during the inspection process
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the unusual incident policy and procedure, that facility failed to include ongoing monitoring of the corrective action plan. These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Policies and procedures for unusual incident reporting have been updated to reflect proper protocol for the ongoing monitoring of the corrective action plan. All staff have been appropriately trained to identify unusual incidents in addition to biweekly quality assurance trainings to ensure ongoing compliance. The Facility Director is responsible for ongoing maintenance and implementation of unusual incident policies and procedures.
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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 seven client records, the facility failed to conduct and document a physical examination in four client records. Client #2 was admitted on August 15, 2019 and was still active at the time of inspection. Client #4 was admitted on August 9, 2019 and was still active at the time of inspection. Client #6 was admitted on June 12, 2019 and was discharged on August 29th 2019. Client #7 was admitted on April 29th 2019 and was discharged on July 31, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to complications surrounding COVID-19, medical facilities and/or transportation programs have suspended or restricted the availability of non-medically necessary/emergency visits. As the county moves towards less restrictive measures, the facility has demonstrated an ongoing effort to work closely with a variety of providers to ensure ongoing compliance with the physical examination requirement. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five client records reviewed.Client #1 was admitted on June 21, 2019 and was still active at the time of the inspection. A treatment plan update was completed on August 12, 2019 and the next update was due no later than September 12, 2019 ; however, there was no update documented in the record until September 30, 2019. Client #3 was admitted on June 27, 2019 and was still active at the time of the inspection. A treatment plan update was completed on July 8, 2019 and the next update was due no later than August 8, 2019 ; however, there was no update documented in the record until August 28, 2019. Client #4 was admitted on August 7, 2019 and was still active at the time of the inspection. A treatment plan update was completed on August 13th 2019 and the next update was due no later than September 13, 2019; however, there was no update documented in the record at the time of the inspection.Client #5 was admitted on February 21, 2019 and was discharged on July 7, 2019. A treatment plan update was completed on March 28, 2019 and the next update was due no later than April 28, 2019 ; however, there was no update documented in the record at the time of the inspection.Client #6 was admitted on June 12, 2019 and was discharged on August 29, 2019. A treatment plan update was completed on July 18,2019 and the next update was due no later than August 18, 2019; however, there was no update documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clinical documentation timeframes have been reviewed and enforced with clinical staff; monthly clinical reviews have been implemented to ensure ongoing compliance. |
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
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include a case consults and verification that work done by the client at the project is an integral part of the treatment plan. Client #1 was admitted on June 21, 2019 and was still active at the time of the inspection. The client record did not contain documentation that work done outside of the clients bedroom was an integral part of the treatment plan and case consults to be completed every 30 days per facility policy.Client #2 was admitted on August 15, 2019 and was still active at the time of the inspection. The client record did not contain documentation that work done outside of the clients bedroom was an integral part of the treatment planClient #3 was admitted on June 27, 2019 and was still active at the time of the inspection. The client record did not contain documentation that work done outside of the clients bedroom was an integral part of the treatment plan. Client #4 was admitted on August 7, 2019 and was still active at the time of the inspection. The client record did not contain documentation that work done outside of the clients bedroom was an integral part of the treatment plan and case consults to be completed every 30 days per facility policy. Client #5 was admitted on February 21, 2019 and was discharged on July 7th 2019. The client record did not contain documentation that work done outside of the clients bedroom was an integral part of the treatment plan. Client #6 was admitted on June 12, 2019 and was discharged on August 29, 2019. The client record did not contain documentation that work done outside of the clients bedroom was an integral part of the treatment plan. Client #7 was admitted on April 29, 2019 and was discharged on July 31, 2019. The client record did not contain documentation that work done outside of the clients bedroom was an integral part of the treatment plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical team has been informed of the need to reflect that work done by client at the facility is an integral part of the treatment plan. Monthly clinical reviews have been implemented to ensure ongoing compliance. |