INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29-30 and June 5, 2024, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all employees received the minimum of at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics using Department approved curriculum within the first two years of employment in six of six applicable records.
Staff #11 was hired August 16, 2021 and still employed. Staff #11 was due to have communicable disease training no later than August 16, 2023 but did not receive TB/STD until September 19, 2023. No documentation was provided for the completion of HIV/AIDS at the time of the inspection.
Staff #12 was hired October 8, 2021 and still employed. Staff #12 was due to have communicable disease training no later than October 8, 2023 but did not receive HIV/AIDS until March 20, 2024. No documentation was provided for the completion of TB/STD at the time of the inspection.
Staff #13 was hired May 2, 2022 and still employed. Staff #13 was due to have communicable disease training no later than May 2, 2024. No documentation was provided for the completion of HIV/AIDS or TB/STD at the time of the inspection.
Staff #14 was hired October 20, 2020 and still employed. Staff #14 was due to have communicable disease training no later than October 20, 2022 but did not receive TB/STD until June 9, 2023. No documentation was provided for the completion of HIV/AIDS at the time of the inspection.
Staff #15 was hired November 29, 2021 and still employed. Staff #15 was due to have communicable disease training no later than November 29, 2023. No documentation was provided for the completion of HIV/AIDS at the time of the inspection.
Staff #16 was hired March 22, 2021 and still employed. Staff #16 was due to have communicable disease training no later than March 22, 2023. No documentation was provided for the completion of HIV/AIDS or TB/STD at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 8, 2023 annual licensure inspection.
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Plan of Correction
On 8/6/24 Chief Executive Officer educated Human Resource Manager regarding the need to ensure all staff complete 6 hours of a Pennsylvania approved HIV/AIDS training and 4 hours of a Pennsylvania approved TB/STD training within the required time frame.
The Human Resource Manager completed an audit on 8/6/24 to ensure all staff persons and volunteers have received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training within the required time frame. All staff who have not completed will have completed by 8/31/24
The Human Resource Manager will complete an ongoing monthly audit. The goal of the audit will be to ensure that all staff persons and volunteers have received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training within the required time frame, with a goal of 100% compliance per month. Oversight of compliance will be monitored by the Committee of the Whole
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a review of the facilities physical plant, the facility failed to ensure that cold foods were kept at or below 40 degrees Fahrenheit.
The refrigerator located in the kitchen had a facility thermometer which read 46 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The refrigerator temperature will be kept at or below 40 degrees. Repairs to the unit will be done if needed to maintain this temperature. French Creek recovery staff will monitor the temperature daily and report to the Director of Maintenance and Executive Director if the refrigerator is not working properly. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in one of five applicable records.
Staff #6 was hired on June 12, 2023 and still employed. The training was completed on November 17, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 8/6/24 Chief Executive Officer educated Human Resource Manager regarding the need to ensure all staff complete training on the use of fire extinguisher before completing orientation.
The Human Resource Manager completed an audit on 8/6/24 to ensure all staff persons and volunteers have received fire extinguisher training within the required time frame. All staff have completed. The Human Resource Manager will complete an ongoing monthly audit.
The goal of the audit will be to ensure that all staff persons have received fire extinguisher training within the required time frame, with a goal of 100% compliance per month. Oversight of compliance will be monitored by the Committee of the Whole
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff were trained to perform assigned tasks during emergencies in one of five applicable records.
Staff #6 was hired on June 12, 2023 and still employed. The training was completed on November 17, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 8/6/24 Chief Executive Officer educated Human Resource Manager regarding the need to ensure all staff complete training on tasks during emergencies before completing orientation.
The Human Resource Manager completed an audit on 8/6/24 to ensure all staff persons and emergency training within the required time frame. The Human Resource Manager will complete an ongoing monthly audit.
The goal of the audit will be to ensure that all staff persons have received emergency training within the required time frame, with a goal of 100% compliance per month. Oversight of compliance will be monitored by the Committee of the Whole
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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 fire drill records, the facility failed to maintain a written fire drill record that includes exit routes utilized during the evacuation.
Fire drill records were reviewed from June 2023 to April 2024. Fire drills documented from June 2023, September 2023, October 2023, November 2023, December 2023, and January 2024 did not indicate which exit routes were utilized during the evacuations.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 8, 2023 annual licensure inspection.
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Plan of Correction
The Plant Operations Manager was educated on 6/5/24 regarding the requirement to maintain written fire drill log including the exit route used. The form used to record fire drills was updated in 8/2023 to include exit route used. The Risk Manager or designee will complete a monthly audit to ensure fire drill records include which exit route was used. Oversight of compliance will be monitored quarterly by the Committee of the Whole. In the event non-compliance is identified, the Plant Operations Manager will be re-educated and/or receive appropriate disciplinary action.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill records, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Fire drill records were reviewed from June 2023 to April 2024. Fire drills documented from June 2023, July 2023, October 2023, November 2023, December 2023, and January 2024 did not indicate that a fire alarm or smoke detector was set off during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Plant Operations Manager was educated on 6/5/24 regarding the requirement to maintain written fire drill log including whether the fire alarm or smoke detector was operative. The form used to record fire drills was updated in 8/2023 to include whether the fire alarm or smoke detector was operative. The Risk Manager or designee will complete a monthly audit to ensure fire drill records include whether the fire alarm or smoke detector was operative. Oversight of compliance will be monitored monthly by the Committee of the Whole. In the event non-compliance is identified, the Plant Operations Manager will be re-educated and/or receive appropriate disciplinary action. |
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 administrative information, the facility failed to document a policy and procedure for notifying the emergency contact for clients who discharge against facility advice in the detoxification and residential level of care.
Additionally, based on a review of client records, the facility failed to document an emergency contact was notified for clients who discharge against facility advice in five of five applicable records reviewed.
Client #1 was admitted to detoxification level of care October 8, 2023, and discharged against facility advice October 14, 2023. There was no documentation of an attempt to contact the emergency contact.
Client #2 was admitted to detoxification level of care December 15, 2023, and discharged against facility advice December 21, 2023. There was no documentation of an attempt to contact the emergency contact.
Client #9 was admitted to residential level of care December 7, 2023, and discharged against facility advice December 27, 2023. There was no documentation of an attempt to contact the emergency contact.
Client #11 was admitted to residential level of care January 10, 2024, and discharged against facility advice January 22, 2024. There was no documentation of an attempt to contact the emergency contact.
Client #14 was admitted to detoxification level of care October 6, 2023, and discharged against facility advice October 13, 2023. There was no documentation of an attempt to contact the emergency contact.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical and Nursing staff will be provided with education by 8/16/24 on the requirement to contact emergency contact after an ASA. Documentation for evidence of education will be retained in the HR personnel file. Clinical and Nursing staff will document this in the electronic medical record including the date and time the Emergency Contact was notified. Director of Quality or designee will complete weekly audits to ensure adherence to the standard. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee in two of four records.
According to agency policy and procedure, performance evaluations will be completed by the team members supervisor, reviewed with the team member and signed by both the supervisor and team member, and then submitted to Human Resources.
Employee #3 was hired as a counselor July 28, 2022 and promoted to clinical supervisor September 10, 2023. An annual performance evaluation signed and dated by the supervisor on March 18, 2024 did not include the dated signature of the employee until May 30, 2024.
Employee #4 was hired as a counselor May 31, 2022 and still in the counselor position. An annual performance evaluation signed and dated by the supervisor on March 18, 2024 did not include the dated signature of the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of HR will review each employee file to verify that staff performance evaluations are reviewed and are signed by the employee by 8/31/24. Director of HR will provide a list of any employees who have not reviewed and signed annual performance evaluation. CEO will require each staff to complete. Weekly audit results will be reported to the CEO each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
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 the disclosure of information in two of fourteen clients records.
Client #6 was admitted to detoxification level of care January 23, 2024 and discharged January 30, 2024. The client's record did not include any informed and voluntary consents signed by the client. It was confirmed that the facility billed the client ' s insurance for services while at the facility.
Client #13 was admitted to residential level of care May 10, 2024 and still a current client. The client's record did not include any informed and voluntary consents signed by the client until May 21, 2024. It was confirmed that the facility billed the client ' s insurance for services between May 10 and May 21, 2024 without a signed consent.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 8, 2023, June 16, 2022 and June 11, 2021 annual licensing inspection.
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Plan of Correction
The Director of admission was trained by the CEO on 6/6/24 related to the correct process of obtaining an informed and voluntary consent upon each client arrival to the facility for admission. The Director admission trained admission staff and nursing staff 6//6/24 on the same procedure. Director of Admissions will complete weekly audits and results will be reported to the CEO each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly |
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 document a purpose of disclosure on the release of information form in four of fourteen records.
Client #1 was admitted to the detoxification level of care October 8, 2023 and discharged October 14, 2023. A release of information to four separate personal contacts was signed by the client on October 8, 2023 but did not indicate purpose of disclosures.
Client #5 was admitted to the detoxification level of care February 15, 2024 and discharged February 22, 2024. A release of information to two separate agencies was signed by the client on February 22, 2024 but did not indicate purpose of disclosures.
Client #7 was admitted to the residential level of care May 7, 2024 and still a current client. A release of information to four separate contacts was signed by the client on May 7, 2024 but did not indicate purpose of disclosures.
Client #14 was admitted to the detoxification level of care October 6, 2023 and discharged October 13, 2023. A release of information to two separate personal contacts was signed by the client on October 6, 2023 but did not indicate purpose of disclosures.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from June 8, 2023, June 16, 2022 and June 11, 2021 annual licensing inspections.
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Plan of Correction
Clinical staff will be provided with education by 8/16/24on required completion of consents, Evidence of education will be retained in the HR personnel file. Audits will take place on a weekly basis to ensure consents are complete in the medical record. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to provide a written policy and procedure on the inspection of medication storage areas that ensures compliance with State and Federal laws and program policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility developed a policy and procedure for the inspection and storage of medication. The Director of Nursing or designee will retrain all Nursing Staff on the Inspection and storage of medication by 8/16/24. The Director of Quality began conducting monthly audits of the completed inspections. The Director of Quality will report any medication errors in the daily meeting and monthly in Committee of Whole |
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 the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered as prescribed in six of fourteen records reviewed.
Client #1 was admitted to Detoxification October 8, 2023 and discharged October 14, 2023. A medication was prescribed to be given three times a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-October 10, 2023 at 2 pm
-October 12, 2023 at 2 pm
-October 13, 2023 at 2 pm
An additional medication was prescribed to be given once daily. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-October 11, 2023 at 8 am
Client #3 was admitted to Detoxification March 8, 2024 and discharged March 12, 2024. A medication was prescribed to be given twice a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-March 9, 2024 at 8 am
-March 9, 2024 at 8 pm
An additional medication was prescribed to be given once daily. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-March 9, 2024 at 8 am
Client #8 was admitted to Residential November 24, 2023 and discharged December 22, 2023. A medication was prescribed to be given three times a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-December 11, 2023 at 2 pm
-December 14, 2023 at 2 pm
-December 15, 2023 at 2 pm
-December 18, 2023 at 2 pm
-December 18, 2023 at 8 pm
An additional medication was prescribed to be given twice a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-December 15, 2023 at 8 am
-December 19, 2023 at 8 pm
Client #10 was admitted to residential December 12, 2023 and discharged January 2, 2024. A medication was prescribed to be given two times a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-December 28, 2023 at 8 am
-December 28, 2023 at 8 pm
-December 29, 2023 at 8 am
An additional medication was prescribed to be given twice a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-December 28, 2023 at 8 am
-December 28, 2023 at 8 pm
-December 29, 2023 at 8 am
Client #11 was admitted to residential January 10, 2024 and discharged January 22, 2024. A medication was prescribed to be given three times a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-January 15, 2024 at 2 pm
-January 16, 2024 at 2 pm
-January 16, 2025 at 8 pm
An additional medication was prescribed to be given twice a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-January 14, 2024 at 8 pm
-January 15, 2024 at 8 am
-January 15, 2024 at 8 pm
-January 16, 2024 at 8 am
An additional medication was prescribed to be given twice a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-January 13, 2024 at 8 pm
-January 14, 2024 at 8 am
-January 14, 2024 at 8 pm
-January 15, 2024 at 8 am
-January 15, 2024 at 8 pm
-January 16, 2024 at 8 pm
-January 18, 2024 at 8 pm
Client #14 was admitted to detoxification October 6, 2023 and discharged October 13, 2023. A medication was prescribed to be given two times a day. The MAR stated " not administered " but reason for missed doses was left blank for the following dates and times:
-October 7, 2023 at 8 pm
-October 8, 2023 at 8 am
-October 9, 2023 at 8 am
-October 9, 2023 at 8 pm
-October 13, 2023 at 8 pm
-October 14, 2023 at 8 am
-October 14, 2023 at 8 pm
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Nursing or designee will educate nursing staff on the proper documentation for unadministered medication on the MAR by 8/16/24. Staff will sign attestation forms acknowledging the education/training they received. Any discrepancies will be addressed with nursing staff and re-education with The Quality Manager will monitor MARs daily and report in daily morning meeting |
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, of a decision to involuntarily terminate the client's treatment at the project in three of four applicable client record.
Client #3 was admitted to detoxification level of care March 8, 2024 and involuntarily discharged March 12, 2024. There was no documentation in the client record to verify that an involuntary termination letter was provided to the client.
Client #4 was admitted to detoxification level of care March 8, 2024 and involuntarily discharged March 11, 2024. There was no documentation in the client record to verify that an involuntary termination letter was provided to the client.
Client #12 was admitted to residential level of care April 12, 2024 and involuntarily discharged April 24, 2024. There was no documentation in the client record to verify that an involuntary termination letter was provided to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Director of Clinical Services will re-educated clinical and nursing department by 8/16/24 on termination letter requirements for administratively discharged clients. Audits will be completed on all administratively discharged clients on a go-forward basis to ensure compliance. Director of Clinical will report compliance with termination letters daily in morning meeting on any prior day administratively discharged clients. Aggregate data will be reported monthly in the Committee of the Whole meeting. The Director of Clinical Service will report findings daily in morning meetings and monthly on the Committee of the Whole. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident.
Unusual Incident Reports were reviewed from December 22, 2023 to May 29, 2024.
The facility had an unusual incident occur on March 13, 2023, March 14, 2023, and April 24, 2024 all which involved sexual or physical assault of a client and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The CEO trained the Quality Manager 8/6/24 on required reporting of events. The Quality Manager will complete an unusual incident report anytime there is sexual or physical assault by a client or staff at French Creek Recovery Center as well as any other required state reportable incidents within the 3 business days following an unusual incident. All staff will be trained to report any unusual incidents to the Administrator. All unusual incidents will be discussed daily in morning meetings. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident.
Unusual Incident Reports were reviewed from December 22, 2023 to May 29, 2024.
The facility had an unusual incident occur on December 22, 2023, December 31, 2023, January 7, 2024, April 9, 2024, April 19, 2024, and May 4, 2024 all which involved police or EMS personnel onsite and the facility did not submit an incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The CEO trained the Quality Manager 8/6/24 on required reporting of events. The Quality Manager will complete an unusual incident report anytime police, fire or ambulance personnel arrive at French Creek Recovery Center as well as any other required state reportable incidents within the 3 business days following an unusual incident. All staff will be trained to report any unusual incidents to the Administrator All unusual incidents will be discussed daily in morning meeting. |
709.62(c)(1) LICENSURE Disclosure documentation
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document that the criteria for admission, treatment, completion, and discharge criteria was disclosed to detoxification clients during intake in seven of seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client signing acknowledgement of receiving a handbook that includes criteria for admission, treatment, completions and discharge criteria. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. Client handbook acknowledgement forms were signed by all current clients and uploaded into electronic health record on 6/6/24. |
709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the project policies, during the intake process, in seven of seven detoxification records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client sign acknowledgement of receiving a handbook that includes client orientation. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
709.62(c)(2)(ii) LICENSURE Orientation - Op hours
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the hours of operation, during the intake process, in seven of seven detoxification records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client sign acknowledgement of receiving a handbook that includes client orientation to hours of operation. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
709.62(c)(2)(iv) LICENSURE Orientation - Services Provided
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the services provided, during the intake process, in seven of seven detoxification records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client sign acknowledgement of receiving a handbook that includes client orientation to services provided. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
709.63(a)(3) LICENSURE Progress notes
709.63. 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:
(3) Progress notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record to include progress notes that are reflective of the clients services received in two of four applicable detoxification records.
Client #1 was admitted to detoxification October 8, 2023 and discharged October 14, 2023. A review of the group progress notes from all group sessions client #1 attended did not include any individualized progress information. Progress notes in the record only stated " participated " .
Client #2 was admitted to detoxification December 15, 2023 and discharged December 21, 2023. A review of the group progress notes from all group sessions client #2 attended did not include any individualized progress information. Progress notes in the record only stated " participated " .
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services staff will be provided with education on required completion of individualized group progress notes for clients by 8/16/24. Evidence of education will be retained in the HR personnel file. Audits will take place on a weekly basis to ensure documentation is complete for detox clients who have discharged. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday with a goal of 100% compliance. |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of two applicable detoxification records.
According to agency policy and procedures manual, aftercare plans should be created for all routine discharges and attempted with all atypical discharges.
Client #5 was admitted to detoxification February 15, 2024 and successfully discharged February 22, 2024. There was no aftercare plan documented in client record #5.
Client #6 was admitted to detoxification January 23, 2024 and successfully discharged January 30, 2024. There was no aftercare plan documented in client record #6.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 8, 2023 annual licensing inspection.
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Plan of Correction
Clinical Services staff will be provided with education on required completion of aftercare plans for detox clients by 8/16/24. Evidence of education will be retained in the HR personnel file. Audits will take place on a weekly basis to ensure documentation is complete for detox clients who have discharged. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday with a goal of 100% compliance. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in six of seven detoxification records reviewed.
The facility's policy and procedure manual states the discharge summary is to be completed for all discharges within seven days.
Client #2 was admitted to detoxification December 15, 2023 and was discharged December 21, 2023. There was an incomplete discharge summary in the client record.
Client #3 was admitted to detoxification March 8, 2024 and was discharged March 12, 2024. There was an incomplete discharge summary in the client record.
Client #4 was admitted to detoxification March 8. 2024 and was discharged March 11, 2024. There was an incomplete discharge summary in the client record.
Client #5 was admitted to detoxification February 15, 2024 and was discharged February 22, 2024. There was an incomplete discharge summary in the client record.
Client #6 was admitted to detoxification January 23, 2024 and was discharged January 30, 2024. There was an incomplete discharge summary in the client record.
Client #14 was admitted to detoxification October 6, 2023 and was discharged October 13, 2024. There was an incomplete discharge summary in the client record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Services staff will be provided with education on required completion of discharge summaries for detox clients by 8/16/24. Evidence of education will be retained in the HR personnel file. Audits will take place on a weekly basis to ensure documentation is complete for detox clients who have discharged. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday with a goal of 100% compliance. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document that the criteria for admission, treatment, completion, and discharge criteria was disclosed to residential clients during intake in seven of seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client signing acknowledgement of receiving a handbook that includes criteria for admission, treatment, completions and discharge criteria. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. Client handbook acknowledgement forms were signed by all current clients and uploaded into electronic health record on 6/6/24.
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709.51(b)(2)(i) LICENSURE Client Orientation to Project
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:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the project policies, during the intake process, in seven of seven residential records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client sign acknowledgement of receiving a handbook that includes client orientation. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
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 client records, the facility failed to document that the client was oriented to the hours of operation, during the intake process, in seven of seven residential records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client sign acknowledgement of receiving a handbook that includes client orientation to hours of operation. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
709.51(b)(2)(iv) LICENSURE Services Provided
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:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the services provided, during the intake process, in seven of seven residential records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff was provided with education 6/6/24 on having each client sign acknowledgement of receiving a handbook that includes client orientation to services provided. Evidence of education will be retained in the HR personnel file. Admissions staff will document and scan the document into the EMR upon the client signing. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday for a period of 45 days, with a goal of 100% compliance. Once 100% compliance is maintained for 45 days, audits will reduce to monthly. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to obtain an informed and voluntary consent from the client prior to the disclosure of information was submitted and approved by the Department for the June 8, 2023, June 16, 2022 and June 11, 2021 annual licensing inspections. Failing to obtain an informed and voluntary consent from the client prior to the disclosure of information was again found to be a deficiency in the June 5, 2024 licensing inspection.
A plan of correction for a consent to release information failing to indicate the purpose of disclosure was submitted and approved by the Department for the June 8, 2023, June 16, 2022 and June 11, 2021 annual licensing inspections. Consents to release information not indicating the purpose were again found to be a deficiency in the June 5, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 8, 2023 annual licensing inspection.
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Plan of Correction
CEO is ultimately responsible for ensuring plans of correction are followed. This will be accomplished through close collaboration with the Director or Quality who is responsible for implementation, tracking, audits, and oversight. Review of progress of stated corrective actions will be addressed daily in the standing leadership meeting which include the following leaders: CEO, Quality Director, Director of Human Resources, Director of Clinical Services, Director of Admissions, and Director of Nursing.Clinical staff will be provided with education 8/16/24 on required completion of consents, Evidence of education will be retained in the HR personnel file. Audits will take place on a weekly basis to ensure consents are complete in the medical record. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday, with a goal of 100% compliance. This audit will be weekly ongoing and not reduced to monthly. |