INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6, 2017 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 to be not 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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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR), the facility failed to ensure that there was one clinical supervisor or counselor for every counselor assistant employed at the facility.The clinical staff at the facility consisted of one clinical supervisor and two counselor assistants. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Graniteville House of Recovery is now in compliance with DDAP's staffing regulations with 1 counselor assistant to 1 counselor ratio, effective 10/06/2017. The Graniteville House of Recovery will continue to remain in compliance with DDAP's clinical staffing regulations with hiring only 1 counselor assistant per 1 full time counselor ratio. |
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
Based on a review of the counselor assistant supervision log and a conversation with the facility staff, conducted on October 6, 2017, the facility failed to ensure that a high school level counselor assistant was directly observed during all clinical sessions for the first 3 months.Employee #3 was hired as a counselor assistant on 8/14/17 and was permitted to counsel clients without being directly observed except when they were doing the one hour direct observation. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee #3, counselor assistant, is no longer in that position, effective 10/06/2017. Clinical Supervisor reviewed Employee #3's client charts to ensure all clients received quality, effective treatment for each individual. Facility Director will closely examine new hires credentials to ensure staff is in compliance with DDAP's counselor assistant direct supervision requirements and continue to monitor supervisions sessions are being conducted between counselor and counselor assistant as required by DDAP. |
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 October 6, 2017, the facility failed to keep the exterior grounds safe and in good repair.The concrete ramp that serves as access to the primary entrance to the facility was cracked and chipped away in two separate areas which presented a tripping hazard.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Graniteville House of Recovery has contacted a repairman to fix the pavement of the exterior ramp. Ramp will be repaired by 11/15/2017 |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on October 6, 2017, the facility failed to maintain water temperature at or below 120 degrees.The handicapped accessible restroom at the rear of the facility near the resident laundry area had hot water measured at 134.8 degrees.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
On the date of inspection, our facility's water temperature was above DDAP's standards. The temperature on the hot water heater was lowered on the date of inspection and we continue to monitor daily to remain in compliance with DDAP's regulations. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection conducted on October 6, 2017, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.The fire extinguisher in the kitchen was rated only B C and did not have an annual inspection tag as it been recently purchased by the facility.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Facility contacted our fire extinguisher provider and had an ABC rated extinguisher placed in the kitchen. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record the facility failed to conduct fire drills from November 2016 thru July 2017.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will conduct unannounced monthly fire drills for all staff and clients monthly and at least once during sleeping hours every 6 months. Alternate exit routes will be used and all information needed, according to DDAP's regulations will be logged. CFO will do monthly audits to ensure the facility remains in compliance. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record, the facility failed to indicate whether the fire alarm or smoke detector was operative during fire drills conducted in August 2017 and September 2017.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Facility failed to document pertinent information on our fire drill simulation logs. We have now updated our logs to include if the smoke detectors were operative during the drill effective 10/06/2017 and will continue to include this information on all logs in the future to remain in compliance. |
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
Seven client records were reviewed on October 6, 2017. The facility failed to document a valid consent to release information form in client records 1, 2, 3, 4, 5, 6 & 7.The facility ' s consent to release information template failed to provide a statement informing the client that the consent could be revoked by the client at any time.Additionally, the facility failed to specify the information to be released, the purpose of the disclosure in records 3-5, and exceeded what is permitted to be released by $ Pa. code 255.5 in records 1, 4, 5 & 7.Client #1 was admitted on 8/18/17 and was an active client at the time of the licensing inspection. A consent to release information to a funding source, dated 8/18/17 allowed for the release of " drug and alcohol treatment, medical records. "Client #2 was admitted on 8/23/17 and was an active client at the time of the licensing inspection. Client #3 was admitted on 9/22/17 and was an active client at the time of the licensing inspection. Two consents to release information, one to a funding source and one to a treatment provider dated 10/5/17, did not specify what information was to be released.Client #4 was admitted on 8/15/17 and was an active client at the time of the licensing inspection. A consent to release information to a funding source, dated 8/15/17 allowed for the release of " drug and alcohol treatment, medical records. "Client #5 was admitted on 9/19/17 and was an active client at the time of the licensing inspection. A consent to release information to a funding source, dated 9/19/17 allowed for the release of "drug and alcohol treatment, medical records." . Additionally, a consent to release information to a treatment provider dated 10/3/17 did not specify what information was to be released; and a consent to release information to another provider did not specify the purpose of the consent.Client #6 was admitted on 9/22/17 and was an active client at the time of the licensing inspection. Client #7 was admitted on 8/25/17 and was discharged on 8/27/17. A consent to release information to a funding source, dated 8/25/17 had the word " All " written in under information to be released.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Facility has updated all consents to include all required information effective 10/14/2017. The facility has also had clients 1 through 6 sign new consents to include required information. Client 7 was not updated as that client was discharged from the program prior to inspection. The Facility Director will conduct monthly file audits to ensure all information and documents are being recorded accurately to remain in compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven client records were reviewed on October 6, 2017. The facility failed to document the therapist's clinical impression of the client's strengths, weaknesses, problems or needs, assets, support systems, coping mechanisms, and negative factors that may inhibit treatment in client records #1-6.Client #1 was admitted on 8/18/17 and was an active client at the time of the licensing inspection. Client #2 was admitted on 8/23/17 and was an active client at the time of the licensing inspection. Client #3 was admitted on 9/22/17 and was an active client at the time of the licensing inspection. Client #4 was admitted on 8/15/17 and was an active client at the time of the licensing inspection. Client #5 was admitted on 9/19/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was dated 2/9/17.Client #6 was admitted on 9/22/17 and was an active client at the time of the licensing inspection. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Facility has since changed our formula of documenting client information to summarize the biopsychosocial assessments in order to better serve our population and provide quality service to our residents.
The clinical supervisor has trained all clinical staff on our new documentation procedure and will train any and all new clinical hires during orientation(prior to start) on documentation of information.
During monthly supervision meetings between clinical staff and clinical supervisor, clinical supervisor will exam all charts to ensure compliance with collection and documentation of client charts. |