INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9 - 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, French Creek Recovery Center 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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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 the physical plant inspection, the facility failed to keep exterior grounds clean and free of hazards.
During the physical plant inspection, the basement white stairway exit door flooded outside the exit door.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Plant Operations will install a roof over the stairwell to prevent water from accumulating outside of the exit door. The Director of Plant Operations will complete environment of care rounds and report the findings in monthly committee meetings to ensure the exit remains clear. |
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 the physical plant inspection, the facility failed to have paper towels or a mechanical dryer in resident bathroom.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The towels were refilled when found to be empty. The Director of Nursing supervises staff members who check twice daily to ensure that the paper towels are in adequate supply. The documentation of these rounds are submitted daily to the Director of Nursing for review. Information is included in the client handbook about how to request additional towels 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 the physical plant inspection, the facility failed to have a functioning sink within the 2nd floor community bathroom.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The water was turned back on for the sink. The Director of Plant Operations completes regular environment of care rounds to ensure that all the bathroom sinks are functioning and reports the findings in monthly Committee Meetings.
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant inspection, the facility failed to have the interior exits and stairs lighted at all times.
During the physical plant inspection, the white staircase had a burned out light between 1st and 2nd floor, the Detox staircase had a burned out light between 1st and 2nd floor, and the 2nd floor swing hallway had a burned out light.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The lightbulbs that were out were immediately changed. The Director of Nursing supervises staff members that complete rounds three times a day to ensure all lightbulbs are working. The documentation from these rounds is submitted each day to the Director of Nursing for review. |
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 fire drill records between September 2020 and April 2021, the facility failed to maintain a written drill documenting the time, exit route used, number of people in the facility at the time of the drill, and problems encountered.
The time was not identified on the November 2020 fire drill.
Exit route used was not identified on the fire drill record for September 2020, October 2020, November 2020, December 2020, January 2021, February 2021, March 2021, and April 2021.
Amount of persons in the facility was not identified on the fire drill record for September 2020, October 2020, November 2020, December 2020, January 2021, February 2021, March 2021, and April 2021.
Problems encountered was not identifed on the fire drill record for November 2020, December 2020, January 2021, February 2021, March 2021, and April 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO revised the fire drill form in accordance with the policy and provided education to staff members. The fire drill forms are reviewed for completion and accuracy following each drill by the Director of Performance Improvement. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill records between September 2020 and April 2021, the facility failed to document which alternate routes where used during fire drills.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill form was revised by the CEO to clearly document which exits were used and which exits were blocked during an evacuation. Staff members were provided education. At the conclusion of each drill the Director of Performance Improvement will review the fire drill form for accurate completion. |
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 policy and procedures, the facility failed to include a written procedure for the case consultation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO developed a policy for case consultation. The policy was approved in Committee Meetings. Staff members were provided education.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the policy and procedures, the facility failed to include accurate procedures for the release of records. The procedure allows for verbal consent if witnessed by 2 parties, and also permits release by medical personnel for purpose of payment and for duty to warn.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has written a policy and procedure for the release of electronic and paper records that only allows for procedures that are in accordance with the Pennsylvania Code. The Director of Health Information Management is responsible for the implementation of and adherence to this policy. |
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to disclosure in three of thirteen client records.
Client # 5 was admitted on May 27, 2021 and did not include a release of information form for the funding source.
Client # 6 was admitted on May10, 2021 and did not include a release of information form for the funding source.
Client #12 was admitted on June 7, 2021. There was not a release of information signed for the laboratory, but information was disclosed on June 7, 2021. There was no release of information signed for the pharmacy, but information was disclosed on June 9, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Health Information Management is completing trainings with all staff persons on proper completion of releases. These trainings will be complete on July 20, 2021. Attempts will be made to contact 5,6 and 12 to complete a release. They will be informed of any disclosure that has occurred, if applicable. All future clients will sign a complete release of information prior to any disclosure of information occurring. A minimum of 30 charts monthly will be audited by the Director of Health Information Management for the accuracy and completion of required releases. The findings from these monthly audits will be reviewed in committee meetings.
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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 client records, the facility failed to obtain an informed and voluntary consent from the client that included the person, agency or organization to whom the information would be disclosed in two of thirteen client records.
Client # 6 was admitted on May 10, 2021, a release of information was signed to the employer, but was missing the employer/agency.
Client # 8 was admitted on May 28, 2021, a release of information was signed but failed to include the person, agency or organization.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Health Information Management is completing trainings with all staff persons on proper completion of releases. These trainings will be complete on July 20, 2021. Attempts will be made to contact 6 and 8 to complete a release, if the release is determined to be necessary for these discharged clients. They will be informed of any disclosure that has occurred, if applicable. All future clients will sign a complete release of information prior to any disclosure of any necessary information occurring. A minimum of 30 charts monthly will be audited by the Director of Health Information Management for the accuracy and completion of required releases. The findings from these monthly audits will be reviewed in committee meetings. |
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.
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Observations
Based on a review of client records, the facility failed to indicate the specific information to be disclosed in one of thirteen records.
Client # 8 was admitted on May 10, 2021. There were four releases of information signed by the client that did not include the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Health Information Management is completing trainings with all staff persons on proper completion of releases. These trainings will be complete on July 20, 2021. Attempts will be made to contact client 8 to complete a release, if the release is determined to be necessary for this discharged clients. Client 8 will be informed of any disclosure that has occurred, if applicable. All future clients will sign a complete release of information prior to any disclosure of any necessary information occurring. A minimum of 30 charts monthly will be audited by the Director of Health Information Management for the accuracy and completion of required releases. The findings from these monthly audits will be reviewed in committee meetings. |
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 client records, the facility failed to indicate the purpose of disclosure in one of thirteen records.
Client #13 was admitted on June 2, 2021 and discharged on June 10, 2021. The client record included five release of information forms that were signed on June 2 and 3, 2021 and none included the purpose of the disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Health Information Management is completing trainings with all staff persons on proper completion of releases. These trainings will be complete on July 20, 2021. Attempts will be made to contact client 13 to correct the release of information if it determined to be necessary to use the release, as this client has discharged. Going forward, all clients will clients will have the purpose of the release of information completed on the form.
A minimum of 30 charts monthly will be audited by the Director of Health Information Management for the accuracy and completion of required releases. The findings from these monthly audits will be reviewed in committee meetings.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to include the dated signature of the witness in one of thirteen records.
Client # 8 was admitted on May 10, 2021. A release of information was signed by the client, but did not include a witness signature.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Health Information Management is completing trainings with all staff persons on proper completion of releases. These trainings will be complete on July 20, 2021. Attempts will be made to contact client 8 to complete a release, that includes a witness signature, if the release is determined to be necessary for this discharged client. All future clients will sign a release of information, that includes a witness signature, prior to any disclosure of any necessary information. A minimum of 30 charts monthly will be audited by the Director of Health Information Management for the accuracy and completion of required releases. The findings from these monthly audits will be reviewed in committee meetings. |
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 client records, the facility failed to offer the client a copy of consents in one of thirteen records.
Client # 8 was admitted on May 10, 2021. Releases of information were signed by the client, but did not indicate a copy was offered.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Health Information Management is completing trainings with all staff persons on proper completion of releases. These trainings will be complete on July 20, 2021. Attempts will be made to contact client number 8 to complete a release, that includes if the client received a copy of the release, if the release is determined to be necessary for this discharged client. All future client's releases will be complete in that t will be identified on the release of information if they received a copy. A minimum of 30 charts monthly will be audited by the Director of Health Information Management for the accuracy and completion of required releases. The findings from these monthly audits will be reviewed in committee meetings. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop a policy and procedure that includes all of the client rights, and failed to notify the client of their rights in thirteen of thirteen client records reviewed.
The policy and procedure denies access (FCRC - RC-03), is missing creed, ethnicity and color in the discrimination section (FCRC RI-01 pg 3 #13), and the client rights and responsibilities (FCRC RI-pg 4 - #17) permits the CEO to remove information from the client record.
Thirteen of thirteen client records reviewed included written acknowledgement the client was given the handbook. Upon review of the handbook, it did not include all of the rights.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights policy was revised to include the required elements by the CEO. The portion of the client rights that included the CEO being able to remove portions of the record was removed. The client handbook was revised to include all client rights as required. All currently admitted clients have been provided a new copy of the updated rights and signed an acknowledgement of the same. All future clients will be informed of the new complete rights and sign documentation of this. The Director of Health Information will audit a minimum of 30 records monthly to ensure proper documentation of clients being informed of their rights. The findings of these audits will be reported in monthly committee meetings. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of policy and procedure and client records, the facility failed to document a policy and inform clients the facility will not discriminate in the provision of services on the basis of creed, ethnicity and color in thirteen of thirteen client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights policy was revised to include the required elements by the CEO. The client handbook was revised by the CEO to include all client rights as required. The facility will notify all clients of their rights under the supervision of the Admission Director. The Director of Health Information will audit a minimum of 30 records monthly to ensure proper documentation of clients being informed of their rights. The findings of these audits will be reported in monthly committee meetings. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of policy and procedure, the facility failed to document a policy and procedure and inform clients the project, facility or clinical director may temporarily remove portions of the record. Documentation was missing in thirteen of thirteen client records.
There were two policy and procedures in the manual. Policy RC03 states, " in the event the clinical team believes review of client record is harmful to client, treatment team will deny " and the policy for Client Rights and Responsibilities (FCRC RI-01 pg 4 #17) states, " CEO can remove portions. "
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights policy and handbook were revised by the CEO. Both now include information that the project, facility or clinical director may temporarily remove portions of the record before it is presented to the client for review if it is believed that review by the client may be detrimental to the client. All current clients have been presented with an updated copy of their rights and signed an acknowledgment of the updated rights. All future clients will be presented with the updated copy of these rights. The Director of Health Information will audit a minimum of 30 records monthly for verification within the record that clients were made aware of this right. The result of these audits will be presented in monthly committee meetings. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on client records reviewed, the facility failed to include verbiage in the client rights form that the client has the right to appeal a decision limiting access to their records in thirteen of thirteen client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights policy and handbook were revised by the CEO. Both now include information that the client may appeal the decision to limit access to their record. All current clients have been presented with an updated copy of their rights and signed an acknowledgment of the updated rights. All future clients will be presented with the updated copy of these rights. The Director of Health Information will audit a minimum of 30 records monthly for verification within the record that clients were made aware of this right. The result of these audits will be presented in monthly committee meetings. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on client records reviewed, the facility failed to include verbiage in the client rights form that the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in thirteen of thirteen client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights policy and handbook were revised by the CEO. Both now include information that client may request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. All current clients have been presented with a copy of these rights and signed and acknowledgement of the updated rights. All future clients will be presented with the updated rights. The Director of Health Information will audit a minimum of 30 records monthly for verification within the record that clients were made aware of this right. The result of these audits will be presented in monthly committee meetings. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on client records reviewed, the facility failed to include verbiage in the client rights form that the client has the right to submit rebuttal data or memoranda to their own records in thirteen of thirteen client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights policy and handbook were revised by the CEO. Both now include information that the client has the right to submit rebuttal data or memoranda to their own records. All current clients have been offered a copy of these rights and signed an acknowledgement of receiving these rights. All future clients will be presented with this updated version of client rights. The Director of Health Information will audit a minimum of 30 records monthly for verification within the record that clients were made aware of this right. The result of these audits will be presented in monthly committee meetings.
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on client records reviewed, the facility failed to document the verbal order was authenticated in writing no later than 24 hours after the order was given in three of three client records reviewed. The facility policy indicates the VO should be signed by who gave the order within 14 business days.
Client #11 was admitted on March 6, 2021, and discharged on March 10, 2021. Verbal order was given on March 7, 2021 and was not signed by the physician.
Client #12 was admitted on June 7, 2021. Verbal order was given on June 9, 2021 at 10:00 am and was not signed by the physician within 24 hours.
Client #13 was admitted on June 2, 2021 and discharged on June 10, 2021. There were three verbal orders documented in the client record, and none of them were signed by the physician within 24 hours. One verbal order was given on June 4, 2021 and was not signed by the physician until June 7, 2021. Two verbal orders were given on June 3, 2021 and were not signed by the physician until June 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility policy was changed to reflect that a verbal order for the detox level of care must be authenticated by the prescriber within 24 hours and all other orders must be authenticated by the prescriber with three business days. Staff members were educated. The Director of Health Information Management will audit a minimum of 30 records monthly to ensure compliance. The findings of these audits will be reported to the committee of the whole. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a review of the policy and procedures and the administrative documentation, the facility failed to include the procedure for the inspection of storage areas and to document the inspection of storage areas at least quarterly.
The policy and procedure, FCRC - MM-11, does not include the time frame for completion, or how the inspections are to be documented.
The facility was approved for services in September 2020 and there is no documentation of an inspection of storage area.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has written a policy and procure that addresses the secure storage of medications that are controlled substances and abusable by clients. The policy includes the requirement of inspection of the medication storage area at least quarterly. The Director of Nursing will be responsible for completing the inspection. The findings related to the inspection will be reported in committee meetings quarterly.
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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of the policy and procedures, the facility failed to include the policy and procedure for the security of drugs, including loss, theft or misuse.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has written a policy and procedure for the security of drugs that includes the loss, theft or misuse of drugs. The Director of Nursing will monitor to ensure adherence to this policy |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, the decision and the reason to involuntarily terminate the client ' s treatment in one of one client record.
Client #11 was admitted on March 6, 2021, and discharged on March 10, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services has educated staff members regarding this requirement. The Director of Health Information management will audit all records of clients that are administratively discharged to ensure that this requirement was completed. |
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.
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Observations
Based on a review of client records, the facility failed to have a complete client record. Follow up information was missing in two of four records.
Client # 3 was admitted on April 01, 2021 and discharged on April 28, 2021. There was not follow-up information in the client record.
Client # 4 was admitted on January 13, 2021 and discharged on February 16, 2021. Follow-up contact was due on February 19, 2021, within three days of discharge. Follow was documented on February 22, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admission will be responsible for completing follow-up calls for clients. The Director of Health Information Management will audit a minimum of 30 records monthly to ensure that follow-up is completed. |