INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3-4th, 2019 of The Graintville House of Recovery by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, The Graintville 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, it was discovered that that Employee #2, whom was hired as a counselor with a Bachelor's degree on September 17, 2019, did not meet the experience requirements to be a counselor. At the time of the hire, the employee only had ten months of experience. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Only Qualified Individuals will be offered the position of Counselor. During the interview process, candidates will be screened for educational background, experience, and educational background. Resumes will be reviewed by Facility Director and/or Executive Director, a copy of diploma and transcripts will be required.
Responsibility of: Facility Director
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The Facility failed to document an indivdual training plan for employee #1, #2, and #3. Employee #1 was hired April 1, 2019 and still employed as project director at the time of the inspection. Employee #2 was hired September 17, 2019 and still employed as counselor at the time of the inspection. Employee #3 was hired June 10, 2019 and still employed as counselor at the time of the inspection. These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Training plans for employee number 1 and 3 have been generated. Employee number two is no longer with the company. Director will continue to monitor and adhere to DDAP requirements to create all training plans for clinical staff based on practicum. |
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
Based on a review of CPR certifications and four weeks of schedules, the facility failed to ensure that at least one person trained in CPR was scheduled at all times which included dates of September 8, 2019 from 3-11pm and September 13th 2019 from 11am-7pm. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation. The facility was out of compliance with this regulation during the September 13, 2018 licensure renewal inspection and the December 27, 2018 follow up inspection.
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Plan of Correction
All employees were certified in CPR by October 31,2019. Moving forward, all new hires will be certified in CPR within 2 weeks of commencement of employment. Director will ensure 24 hour coverage of the facility of those that have already completed CPR certification and will monitor new hires receive certification in allotted time frame. |
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 review of the project's policy and procedure manual, 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
Moving forward, Graniteville's Executive staff will be responsible to schedule an annual meeting to review facility's policies and procedures manual with Facility Director. Meeting will be conducted at the end of each fiscal year.
To suffice this years review of our manual, we will conduct a review at the end of the calendar year. |
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 releases will be reviewed for accuracy of information upon completion, and again during the chart audit procedure performed by Facility Director on a monthly basis at minimum. Overnight personnel will also perform chart quality assurance audits and bring any discrepancies to Facility Director's immediate attention.
All discrepancies on consents found during audit have been corrected.
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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
A staff meeting was scheduled on 10/29/19 to inform all personnel handling medication and documents pertaining to them on our policies and procedures of where to store, how to document, what to do with old logs, etc.
Continued med room audits will be conducted overnight during quality assurance personnel to ensure accuracy in compliance.
Update: Records for removal of outdated drugs will be maintained in a binder in the medication room by the Community Care Coordinators and will not be disposed of. Facility Director will review record monthly for accuracy. Records shall be kept in order by date for a minimum of 2 calendar years.
Responsibility of: Facility Director
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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
A staff meeting was scheduled on 10/29/19 to inform all personnel handling medication and documents pertaining to them on our policies and procedures. All staff was informed of how to properly record all information on the med logs. Med logs have also been updated to reflect all necessary information.
Continued med room audits will be conducted overnight during quality assurance personnel to ensure accuracy in compliance. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the facility policy and procedure manual, the policy and procedure manual failed to inlcude a procedure addressing the prompt review and identification of the causes directly or indirectly responsible for the unusual incident. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will develop a policy and procedure to address the prompt review and identification of the causes directly or indirectly responsible for the unusual incident by January 31, 2020. All staff will be trained by February 28, 2020. A backup policy and procedure manual will be created and monitored by the Facility Director and will be subject to annual review with the board by the Executive Director.
Responsibility: Facility Director and Executive Director
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility policy and procedure manual, the policy and procedure manual failed to inlcude a procedure addressing the Implementation of a timely and appropriate corrective action plan, when indicated. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will develop a policy and procedure to address the implementation of a timely and appropriate corrective action plan, when indicated. The facility had a policy and procedure in place to address a timely and appropriate corrective action plan when indicated, but was unavailable at the time of the inspection and needs to be created. The Facility Director will develop a policy and procedure to address the timely and appropriate corrective action plan by January 31, 2020. All staff will be trained by February 28, 2020. A backup policy and procedure manual will be created and monitored by the Project/Facility Director and will be subject to annual review with the board by the Executive Director.
Responsibility: Facility Director and Executive Director
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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 facility policy and procedure manual, the policy and procedure manual failed to inlcude a procedure addressing the ongoing monitoring of the corrective action plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Graniteville has included that a review of all incident reports will be analyzed on a quarterly basis to safeguard further incidents by reviewing the corrective action plans of any and all incidents that occurred during that quarter. |
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
All clients shall have a physical scheduled with Primary Care Physician within 24 business hours of admission. Policy manual has been updated to reflect each client will receive a physical within 7 days of admission. Physicals will be scheduled by intake coordinator or counselor during the admission assessment process.
Facility Director will monitor to ensure compliance. |
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 counselors will use the Outlook Calendar feature to document date that next treatment plan update is due for each client they are working with. On the date due, counselor will update the treatment plan with the client.
Facility Director will monitor compliance during monthly case consults. |
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
All treatment plans have been updated to reflect life skills as part of an important role in their treatment reflective on their tx plans.
Case consult meetings are scheduled every 30 days. Facility Director is responsible for rescheduling if need be, but must ensure one is being conducted and documented on a monthly basis. |