INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted May 2, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, French Creek Recovery Center was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 during a complaint investigation on May 2, 2023, the facility failed to maintain the grounds of the facility clean, safe, sanitary and in good repair at all times.
The following was observed:
- The side porch wall with window has protruding exposed screws.
- The side porch facing the road has large cracks in cement with loose gravel and a loose railing.
- The second story rooftop deck has a broken and loose railing.
- The stairs leading from the parking lot to the facility entrance has broken cement steps
- The side walkway to the front yard has two loose square brick paver steps.
This was discussed with staff during the investigation.
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Plan of Correction
Maintenance Director removed protruding exposed nails on 5/8/23.
Maintenance Director repaired side porch facing the road and railings on 5/8/23.
Maintenance Director repaired second story rooftop deck with broken and loose railing on 5/8/23.
Maintenance Director repaired broken cement steps on the stairs leading from the parking lot to the facility entrance on 5/8/23.
Maintenance Director repaired the two loose square brick paver steps on the side walkways to the front yard on 5/8/23.
Maintenance Director completed an inspection on 5/12/23, of the grounds to ensure facility grounds are clean, safe, sanitary and in good repair with no additional findings.
Maintenance Director or designee will complete an inspection one time per month during leadership rounds to ensure facility grounds are clean, safe, sanitary and in good repair. Corrective actions will be addressed as needed based on the findings of the audit. All findings will be submitted to the Committee of the Whole for review.
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on May 2, 2023, the facility failed to maintain furnishings in a state of good repair.
The client living room/lounge was observed to have multiple stained chairs, two torn chairs, and three chairs with bottom material hanging (one with stuffing sticking out and one with an exposed spring).
This was discussed with staff during the investigation.
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Plan of Correction
Maintenance Director removed and replaced two torn chairs and three chairs with bottom material hanging on 5/2/23.
Maintenance Director cleaned or replaced multiple stained chairs on 5/2/23.
Maintenance Director completed an inspection on 5/12/23 to ensure all furnishings are in a state of good repair with no additional findings.
Maintenance Director or designee will complete inspection one time during leadership rounds per month to ensure facility grounds are clean, safe, sanitary and in good repair. Corrective actions will be addressed as needed based on the findings of the audit. All findings will be submitted to the Committee of the Whole for review.
P089: Heating and cooling- facility was observed to have a space heater that was not permanently mounted to the wall.
POC=
Maintenance Director immediately removed heater from building on 5/2/23.
Maintenance Director completed a facility inspection on 5/12/23 to ensure there were no heaters that needed to be mounted with no other findings noted.
Maintenance Director or designee will complete inspection one time per month during leadership rounds to ensure there no heaters present that are not permanently mounted to the wall. Corrective actions will be addressed as needed based on the findings of the audit. All findings will be submitted to the Committee of the Whole for review.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on May 2, 2023, the facility was observed to have a space heater that was not permanently mounted or installed.
An unmounted space heater was observed in the CEO/Facility Director's office.
This was discused with staff during the investigation.
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Plan of Correction
Maintenance Director immediately removed heater from building on 5/2/23.
Maintenance Director completed a facility inspection on 5/12/23 to ensure there were no heaters that needed to be mounted with no other findings noted.
Maintenance Director or designee will complete inspection one time per month during leadership rounds to ensure there no heaters present that are not permanently mounted to the wall. Corrective actions will be addressed as needed based on the findings of the audit. All findings will be submitted to the Committee of the Whole for review.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client charts, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 5 was admitted on March 30, 2023 and was discharged on May 2, 2023. The treatment plan dated April 6, 2023 called for weekly individual sessions. Individual session documentation was missing for the weeks of April 13, 20 and 27, 2023.
Client # 6 was admitted on April 7, 2023 and was a current client at the time of the investigation. The treatment plan dated April 13, 2023 and called for weekly individual sessions. Individual session documentation was missing for the weeks of April 22 and 29, 2023.
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Plan of Correction
Clinical Supervisor completed audit on all active client charts on 5/12/23 to ensure counseling services were provided according to the individual treatment and rehabilitation plan- no negative findings were noted.
Clinical Supervisor re-educated clinical staff on 5/12/23 regarding the policy and process of providing counseling services according to the individual treatment and rehabilitation plan.
Clinical Supervisor or designee will complete a weekly audit for one month to ensure compliance to the standard. If adherence to the standard is consistently met the Clinical Supervisor or designee will reduce the audit to once per month. The goal of the audit will be to ensure counseling services are provided according to the individual treatment and rehabilitation plan with a goal of 100% compliance. Oversight of compliance will be monitored quarterly by the Committee of the Whole. In the event non-compliance is identified, the clinician will be re-educated and/or receive appropriate disciplinary action.
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client charts, the facility failed to ensure a complete client record to include progress notes in two out of seven charts reviewed.
Client 4 was admitted on February 26, 2023 and discharged on March 14, 2023. The record of service showed an individual counseling session occurred March 8, 2023 but there was no progress note observed in the chart.
Client 7 was admitted on March 29, 2023 and was a current client at the time of the investigation. The record of service showed an individual counseling session occurred on April 27, 2023 but there was no progress note observed in the chart.
This was discussed with staff during the investigation.
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Plan of Correction
Clinical Supervisor completed audit on all active client charts on 5/12/23 to ensure client records included progress notes with no negative findings noted.
Clinical Supervisor re-educated staff on 5/12/23 on the need to process clinical documentation into the client medical records by the end of their shift.
Clinical Supervisor or designee will complete a weekly audit for one month to ensure compliance to the standard. If adherence to the standard is consistently met the Clinical Supervisor or designee will reduce the audit to once per month. The goal of the audit will be to ensure that clinical documentation is placed in the client charts with a goal of 100% compliance per month. Oversight of compliance will be monitored quarterly by the Committee of the Whole. In the event non-compliance is identified, the clinician will be re-educated and/or receive appropriate disciplinary action.
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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.
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Observations
Based on a review of client records during a complaint investigation conducted on May 2, 2023, the facility failed to provide a complete client record which is to include aftercare plans, in 3 out of 4 applicable client records. Per the facility's Discharge Planning & Process policy, every client will receive a continuing care plan regardless of discharge type.
Client # 1 was admitted on March 3, 2023, and discharged on March 24, 2023. This record did not contain an aftercare plan.
Client # 2 was admitted on March 4, 2023, and discharged on March 17, 2023. This record did not contain an aftercare plan.
Client # 4 was admitted on February 26, 2023, and discharged on March 14, 2023. This record did not contain an aftercare plan.
This was discussed with facility staff during the investigation.
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Plan of Correction
Clinical Supervisor re-educated clinical staff on 5/12/23 regarding the policy and process of giving an aftercare plan to all discharging clients regardless of discharge type. Any refusal or inability to engage in aftercare planning by the client will be documented in the medical record.
Clinical Supervisor or designee will complete a weekly audit for one month to ensure compliance to the standard. If adherence to the standard is consistently met the Clinical Supervisor or designee will reduce the audit to once per month. The goal of the audit will be to ensure an aftercare plan is given to all discharging clients with a goal of 100% compliance per month. Oversight of compliance will be monitored quarterly by the Committee of the Whole. In the event non-compliance is identified, the clinician will be re-educated and/or receive appropriate disciplinary action.
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