INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 23-24, 2020 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 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:
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of a job description, the facility organization chart and discussions with facility staff, the facility failed to hire an individual as project director who meets the educational and experiential qualifications for the position of project director. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Current Facility Director has been repositioned as Project/Facility Director to meet position requirements. During the interview process, candidates will be screened for educational and experiential background. Resumes will be reviewed by Project/Facility Director or the Executive Director in event of Project/Facility Director vacancy, and a copy of diploma and transcripts will be required. Employee Education and Experience Compliance Summaries will be required for all positions for which experience/education requirements exist.
Responsibility of: Project/Facility Director
|
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.
|
Observations
Based on a review of personnel records, it was determined that Employee #4, whom was hired as a counselor on September 21, 2020, did not meet the experience requirements to be a counselor. At the time of hire, employee #4 only had four months of experience. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On 12/01/2020 Employee #4 signed and agreed to a new job description as a "counselor assistant." Position description has been updated in the policy and procedure manual; an individualized training plan was developed which shall include a direct supervised training period starting 12/01/2020?06/01/2020 which shall include at least 1 hour of direct supervision per week as documented in records. Based on satisfactory progress documented in supervision, observation, and job performance standards, employee #4 will progress to having 6 subsequent months of close supervision; assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level and knowledge.
Employee Education and Experience Compliance Summaries will be required for all positions for which experience/education requirements exist.
Responsibility of: Project/Facility Director
|
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.
|
Observations
Based on a discussion with the facility director and a review of the policy and procedures manual, the facility failed to complete an assessment of staff training needs for training year 2020.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Project/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.
Project/Facility Director will continue to develop 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 Project/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.
|
Observations
Based on a discussion with the facility director and a review of the policy and procedures manual, the facility failed to complete an overall plan for addressing training needs for the 2020 training year. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Project/Facility Director has developed and identified immediate educational/training needs based on current staff assessment needs, current treatment modalities/ best practice procedures, and mandated qualifications and requirements and will continue on a semi-annual basis.
Project/Facility Director has developed a standardized assessment of employees training needs based on peer evaluations, self-assessments, and yearly job performance reports.
A minimum of 45 minutes per month of training shall be initiated for CCC and Counselor staff as determined by Project/Facility Director. Project/Director will meet monthly with all client-oriented staff to review standards, policies, and procedures to assess training needs and update overall training plans.
|
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.
|
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 October 18, 2020 from 3-11pm, October 23, 2020 from 8-11pm, October 25 from 3-11pm, October 30 from 8-11pm, October 31 from 3-11pm, November 1 from 3-11pm. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the previous three inspections on September 13, 2018, December 27, 2018 and October 4, 2019.
|
Plan of Correction
Project/Facility Director shall ensure that all new employees are CPR certified within 90 days of hire AND shall not work unassisted by a certified CPR staff until proof of certification is verified. GHOR hiring policies/ procedures shall reflection the CPR certification requirement. CPR certification/re-certification shall be reviewed as part of the individualized training plans as regulated. Project/Facility Director shall review schedules as created to ensure at least one employee is CPR certified at all times |
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.
|
Observations
Based a on physical plant inspection, the facility failed to ensure the grounds are kept in good repair at all times as evidenced by the driveway which had significant potholes and ditches.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The parking lot and driveway will be sufficiently labeled to ensure non-used areas are not breached. Main driveway will be completely leveled and graveled by June 2021 for ease of access. Responsibility of Site and Equipment Manager. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
|
Observations
Based on a physical plant inspection on November 23, 2020 at 12:30pm, the door to the records room was observed not latched and therefore could be accessed without a key. The filing cabinets within the records room were also unlocked and could be accessed without a key.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Locking mechanisms on sensitive areas will be changed to automatic locking systems to maximize security. Automatic closure mechanisms were installed on 1/4/21. Automatic locking mechanisms will be installed by 1/31/21. Additionally, security and confidentiality policies will continue to be reinforced through direct staff communication and trainings. Responsibility of Project/Facility Director. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that all consent to release forms contained the specific information disclosed in two of seven client records. Client #1 was admitted on July 14, 2020 and was still active at the time of inspection. A consent to release form signed August 1, 2020 to an outside source failed to contain the specific information that can be released. Client #4 was admitted on September 30, 2020 and was still active at the time of the inspection. A consent to release form was signed on October 15, 2020 to an outside source that failed to contain the specific information can be released. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Project/Facility Director shall ensure all employees complete DDAP training module for Drug & Alcohol Confidentiality within 90 days of hire and shall be reviewed annually through signed yearly attestation review system. Project/Facility Director will conduct and document weekly caseload supervision and review of all clinical charts for accuracy, quality, and clinical compliance standards at least once monthly, including a minimum of 5 different charts per week on a rotating basis. |
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.
|
Observations
Based on a review of client medical records, the facility failed to ensure that missed medication was documented in the medical records. The facility also failed to keep documentation of change of dosage/medications. The facility was documenting medication changes on a separate 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.This is a repeat citation from the inspection on October 4, 2019.
|
Plan of Correction
Graniteville has adopted a fully electronic records management system as of November 2020 which consolidates and automatically tracks each client record for missed medications and changes.
Project/Facility Director will review medication record policies and procedures monthly will all relevant staff based on bi-weekly medical audit review. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of seven client records, the facility failed to complete and document a physical examination on all seven clients. This is a repeat citation from the previous inspection on October 4,2019.
|
Plan of Correction
As of 12/18/20, Administrative Assistant will schedule initial physical exam as mandated within 7 days and then ensure receipt of Physical Examination to be added to client chart. Project/Facility Director has developed and mandated a "Proof of Physical Exam Form" to be completed by the examining physician. Facility Director will review and audit each client chart at least once monthly to ensure compliance. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of three applicable records, the facility failed to document an aftercare plan in two client records. Client #5 was admitted on August 16, 2019 and was discharged on June 24, 2020. Client #6 was admitted on May 13, 2020 and was discharged on October 23, 2020.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The Project/Facility Director will conduct and document weekly caseload supervision with each counselor including discussion of aftercare planning / documentation. Project/Facility Director review and audit all clinical charts for accuracy, quality, and clinical compliance standards at least once monthly, including a minimum of 5 different charts per week on a rotating basis. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on review of three applicable client records, the facility failed to document a discharge summary in one client record. Client record #5 was admitted on August 16, 2019 and was discharged on June 24, 2020. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The Project/Facility Director will conduct and document weekly caseload supervision with each counselor including discussion of aftercare/discharge planning and documentation. Project/Facility Director review and audit all clinical charts for accuracy, quality, and clinical compliance standards at least once monthly, including a minimum of 5 different charts per week on a rotating basis. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of three applicable records, the facility failed to document a follow up in two client records. Client #6 was admitted on May 13, 2020 and was discharged on October 23, 2020.Client #7 was admitted on May 22, 2020 and was discharged on August 28, 2020.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Project/Facility Director review and audit all clinical charts for accuracy, quality, and clinical compliance standards at least once monthly, including a minimum of 5 different charts per week on a rotating basis. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on a review of seven client records, the facility failed to document that all work done by clients at the project is an integral part of his treatment and rehabilitation plan in all seven client records. These findings were discussed with facility staff during the inspection process. This is a repeat citation from the previous inspection on October 4, 2019.
|
Plan of Correction
The Project/Facility Director will conduct and document weekly caseload supervision with each counselor including discussion of treatment planning and documentation. Project/Facility Director review and audit all clinical charts for accuracy, quality, and clinical compliance standards at least once monthly, including a minimum of 5 different charts per week on a rotating basis. During chart review, Project/Facility Director will ensure that all work completed by clients is an integrated part of the client treatment plan. |