INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and licensure renewal inspection conducted on October 12 and 13, 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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704.12(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/counselor ratios. The facility has an exception allowing a client/counselor ratio for 1/10. At the time of the inspection, the project/facility director was the only clinician providing on-site counseling, and the facility had a census of 24 clients, resulting in a ratio of 1/24. The facility contracts with two additional counselors, but they only provide off-site telehealth counseling, so they are not included in the client/counselor ratio. The Department has not granted any waivers for telehealth to replace in-person counseling in residential facilities. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the Mach 31, 2021 - April 1, 2021 provisional follow up inspection.
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Plan of Correction
The facility presently maintains, and will continue to maintain, on-site clinical ratios in according with 1 FTE clinician (35 hours) for every 10 clients pursuant to 28 Pa. Code §§ 704.12, et seq. Clients are assigned to an on-site clinician in accordance with 1:10 ratios. On-site clinical staffing ratios are currently maintained by facility director, clinical supervisor, and counselor assistant. Additionally, documentation of Counselor Assistant supervision was provided to DDAP on January 26, 2022. The facility will continue to utilize on-site clinicians as defined within 28 Pa. Code §§ 704.5 - 28 Pa. Code §§ 704.8, et seq. in order to maintain on-site clinical service delivery in addition to telehealth clinical service delivery. Utilizing an inter-and-multidisciplinary treatment management system, the facility will continue to meet clinical service needs through on-site and telehealth service options, while still maintaining the on-site clinical ratio. Clinical service load is, and will be, shared across the treatment team. The facility will arrange admissions in accordance with on-site staffing ratios. It is the ongoing responsibility of the Facility Director to maintain appropriate clinical staffing as detailed in 28 Pa. Code §§ 704.12, et seq. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an unannounced onsite provisional follow up and annual licensing inspection on October 12 and 13, 2021, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. While conducting the physical plant inspection, security cameras were observed in the large room with chairs on the left side of the business office and in the room with purple walls across from the conference room. Neither room had doors, and the room with the chairs had windows that were not fully covered that led to a porch where clients went to smoke. When speaking to clients, they indicated those rooms were both used for group sessions.When the inspectors arrived, a client was in the conference room participating in a telehealth session. The room did not have window coverings and a window was open while other clients were outside on the porch smoking.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A work request has been submitted to have doors installed in the purple room. All other counseling spaces are already in compliance and at no time have cameras ever been used or mounted in counseling spaces including the purple room. Authorized counseling spaces will be labelled and clinical staff will continue to ensure counseling is taking place in authorized spaces only. Responsibility of Executive Director, to be completed by January 2022 in accordance with qualified professional availability. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a review of the physical plant, the facility failed to provide either individual paper towels or a mechanical dryer in all client bathrooms. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Paper towels remain available for client use. Availability of paper towels is monitored daily and replenishment is provided as needed. Responsibility of Facility Director. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a review of the physical plant, the facility failed to ventilate washrooms by exhaust fan or window.The client bathroom across from client bedroom number seven had tape over the switch to turn on the fan. When the Executive Director turned the fan on, it was loud and noisy, and when tested, it was not providing ventilation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Exhaust fan testing at the time of inspection was insufficient and the fan will be assessed by a qualified professional. The bathroom in reference is unavailable for client use until a qualified professional may assess exhaust fan functionality and repair if needed. |
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 review of the physical plant, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.The toilet in the back bathroom near the laundry room was out of order during the inspection. There was a plunger sitting on top of the toilet, and when asked, the facility could not identify the length of time it had been out of order or if a work order had been placed to fix it. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bathroom in reference was unavailable during service for less than 8 hours during sleeping hours and was immediately available for use including on the day of inspection. Facility staff has and will continue to monitor and maintain bathroom facilities to ensure cleanliness and functionality. Please see attachment #P067 |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's "Emergency Evacuation Simulation Log" from July 2020 to October 2021, the facility failed to maintain a written fire drill record to include the time, problems encountered and whether the fire alarm or smoke detector was operative.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff members have been retrained on log maintenance to include positive affirmation of fire alarm functionality. New staff are initially trained on fire and evacuation procedures during onboarding and ongoing training is maintained through routine and regular staff meetings. Ongoing responsibility of the Facility Director. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's "Emergency Evacuation Simulation Log" from July 2020 to October 2021, the facility failed to document that a fire drill was conducted during sleeping hours at least every 6 months. The facility's "Emergency Evacuation Simulation Log" failed to provide times to determine if a fire drill had been conducted during sleeping hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill logs were maintained to reflect sleeping hours fire drill and were last completed 7/25/21 at 3:15am. New log templates were created on October 13, 2021 to ensure more specificity and ease of record keeping. Please see attachment #P149. Fire drills will continue to be performed as scheduled and/or required including sleeping hours fire drills biannually. Ongoing responsibility of Facility Director to ensure fire drills are recorded appropriately through biannual log review. |
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 facility's "Emergency Evacuation Simulation Log" from July 2020 to October 2021, the facility failed to set off a fire alarm or smoke detector during each fire drill. Under the category of the facility's "Emergency Evacuation Simulation Log" labeled "Did smoke system alarm", "cell phone" was written for each drill. The facility does not have an exception to utilize a cell phone rather than setting off a fire alarm or smoke detector. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff members have been retrained on log maintenance to include positive affirmation of fire alarm functionality. New staff are initially trained on fire and evacuation procedures during onboarding and ongoing training is maintained through routine and regular staff meetings. Ongoing responsibility of the Facility Director. |
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 facility's written manual delineating project policies and procedures, the project director failed to prepare, annually update and sign the manual. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
2021 annual review and signature will occur as scheduled for December 8, 2021. Ongoing responsibility of Executive Director to ensure Facility Director annual review is complete. |
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 written manual delineating project policies and procedures, the governing body failed to adopt a written plan for the coordination of client treatment and rehabilitation services which includes, written procedures for the management of treatment/rehabilitation services for clients to include case consultations. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the March 31, 2021 - April 1, 2021 provisional follow up inspection.
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Plan of Correction
Case consultations were removed from the existing procedures at the recommendation of licensing personnel during March 2021 survey. Case consultations have been re-added to treatment management procedures and active client records beginning Dec 8, 2021 forward will include case consultations. Completion of case consultations will be monitored during chart audits. This will be the ongoing responsibility of Clinical Supervisor. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent in one client record did not include the name of the person, agency or organization to whom disclosure was made.Client # 6 was admitted on March 31, 2021 and discharged on April 30, 2021. An informed and voluntary consent signed and dated on March 31, 2021 by the client for the disclosure of information listed "legal agency" but did not identify the name of the legal agency or organization.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All client records in reference are from the previous inspection period. Release templates were updated after March 31, 2021 inspection. Consents from last inspection to present have been appropriately maintained. As of April 2021, consents have been and will continue to be monitored during chart audits. This continues to be the ongoing responsibility of Clinical Supervisor. Please see attachments #0277, 0281, 0289. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent in one client record did not include the purpose of disclosure.Client # 5 was admitted on March 22, 2021 and discharged on June 11, 2021. An informed and voluntary consent from the client for the disclosure of information to a friend signed and dated on March 22, 2021 did not include the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consent in reference was redone to include all required information on May 20, 2021 with a valid as of date of March 22, 2021 which was available for review at the time of inspection. Please see attachment #0281. Release templates were updated after March 31, 2021 inspection. Consents from last inspection to present have been appropriately maintained. As of April 2021, consents have been and will continue to be monitored during chart audits. This continues to be the ongoing responsibility of Clinical Supervisor. Please see attachments #0277, 0281, 0289. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent in one client record did not include whether a copy of a consent was offered to the client.Client # 5 was admitted on March 22, 2021 and discharged on June 11, 2021. An informed and voluntary consent from the client for the disclosure of information to a Victim Resources Center signed and dated on March 22, 2021 did not include whether a copy was offered to the client. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the March 31, 2021 - April 1, 2021 provisional follow up inspection.
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Plan of Correction
All client records in reference are from the previous inspection period. Release templates were updated after March 31, 2021 inspection. Consents from last inspection to present have been appropriately maintained. As of April 2021, consents have been and will continue to be monitored during chart audits. This continues to be the ongoing responsibility of Clinical Supervisor. Please see attachments #0277, 0281, 0289. |
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 medication administration records, the facility failed to document the reasons medication was not given as prescribed. The medication administration record was not signed to verify the client received the medication as prescribed nor was there a reason documented for the missed medication in four of seven client records reviewed.Client #1 was admitted on May 17, 2021 and was still active at the time of the inspection. There was no documentation for missed doses of medication for the following: Methocarbamol on October 8, 9, and 10, 2021Client #3 was admitted on September 20, 2021 and was still active at the time of the inspection. There was no documentation for missed doses of medication for the following:Furosemide, Trazodone, Mirtaziphine, Duloxetine on October 11, 2021Client #4 was admitted on September 2, 2021 and was still active at the time of the inspection. There was no documentation for missed doses of medication for the following:Buprenorphine on September 28, 29, 30, 2021 and October 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 2021. Client #5 was admitted on March 22, 2021 and discharged on June 11, 2021. There was no documentation for missed doses of medication for the following:Aspirin Adult 81 mg on May 11, 2021 and May 14, 2021Doxepin HCL 75 mg on May 17, 2021 These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff members have been retrained to ensure that medication refusals or miss reasons are appropriately documented in writing in medication record. Ongoing training is maintained through routine and regular staff meetings. Responsibility of Facility Director. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of one applicable client record, the facility failed to provide the client an opportunity to request reconsideration of a decision terminating treatment.Client # 6 was admitted on March 31, 2021 and discharged on April 30, 2021. There was not documentation that the facility provided the client an opportunity to request reconsideration of a decision terminating treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is an existing facility policy to allow the client the opportunity to request reconsideration of a decision to terminate treatment as detailed in the Grievance and Appeals policy signed and acknowledged upon a client's admission and which further remains accessible in appropriate client areas. A copy of Client #6's signed acknowledgement of the Grievance and Appeals policy is attached; further note that Client #6 accepted a copy of the signed policy. Administrative Discharge notices were updated on October 13, 2021 to reflect a reiterated acknowledgement of the grievance and appeals policy and their opportunity to request reconsideration of a decision terminating treatment. Please see attachment #0335. Pre-existing templates have been removed from use; clinical supervisor will continue to ensure appropriate templates are used during routine, at least monthly, chart audits. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of seven client records, the facility's intake procedures failed to document client orientation to the project that includes a familiarization with the hours of operation in all seven records reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The words "24 hours" have been added to the Client Handbook. Please see attachment #1743. |
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 document a physical examination in four client records reviewed. Client #1 was admitted on May 17, 2021 and was current at the time of the inspection.Client #3 was admitted on September 20, 2021 and was current at the time of the inspection.Client #4 was admitted on September 2, 2021 and was current at the time of the inspection.Client #6 was admitted on March 31, 2021 and discharged on April 30, 2021. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the November 23 - 24, 2020 annual licensing inspection, and the March 31 - April 1, 2021 provisional follow-up inspection.
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Plan of Correction
In accordance with the facility's treatment protocol, a physical exam is scheduled for clients within 7 days of admission. Facility staff provide clients with a blank "Graniteville Proof of Physical Form" to have completed by their attending medical professional. In the event that the client fails to return the Graniteville Physical Form, facility staff directly contact the offices of the client's healthcare providers to obtain documentation of the client's completed medical visit. If the documentation provided by the healthcare provider does not include documentation of a physical examination of the body or systems, the facility will directly contact the offices of the client's healthcare providers to obtain documentation of a physical examination or to reschedule another physical exam of the client. The Administrative Assistant will be responsible for ensuring documentation of physical examination is included in the chart. The Facility Director will have the duty to verify compliance through monthly chart reviews. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of three discharged client records, the facility failed to provide a complete client record on all three clients which included information relative to the client's involvement with the project including case consultation notes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case consultations were removed from the existing procedures at the recommendation of licensing personnel during March 2021 survey. Case consultations have been re-added to treatment management procedures as of October 13, 2021. Active clients from Dec 8, 2021 forward will include case consultations. Completion of case consultations will be monitored during chart audits. This will be the ongoing responsibility of the Clinical Supervisor. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
During an unannounced onsite provisional follow up and annual licensing inspection on October 12 and 13, 2021, the facility failed to provide full and free access to the records of the facility and its clients.Upon arrival to the facility, the Executive Director and Project Director/Facility Director were asked to provide a list of all clients admitted from March 2021 to present. The facility provided a list of fifty-two clients. They were then asked to provide full access to each client record. The facility requested the specific names of clients the inspectors wanted to review. The facility was again asked to provide full access to all client records on the list that was provided. Over the two-day inspection, full access was not granted by the facility to all client records. Additionally, the access that was provided to client records did not always include the entire client record. Inspectors were required to ask for access to the medical records, clinical progress notes and discharge information in various records during the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility operates with a state-of-the-art electronic record keeping system with infrastructural protocols in place so as not to compromise client records to external and/or unapproved users. Since the October 2021 inspection, record retrieval protocol has been reviewed and optimized for efficiency. For all future record requests from DDAP, the Executive Director will immediately provide full and free access to the records of the facility and its clients upon request. Client record requests will continue to be the responsibility of the Executive Director. Client records will be available timely and upon request in accordance with 28 PA Code 709.15. |