INITIAL COMMENTS
|
This report is a result of an on-site provisional follow-up inspection conducted on December 17-19, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facilities physical plant, the facility failed to ensure cold foods were kept at or below 40 degrees Fahrenheit and frozen foods were kept at or below 0 degrees Fahrenheit.
The refrigerator located in the kitchen had a facility thermometer which read 43 degrees Fahrenheit and a second thermometer in the same fridge which read 45 degrees Fahrenheit. The walk-in freezer in the basement thermometer read 10 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 5, 2024 annual licensure inspection.
|
Plan of Correction
Plan of Correction: The temperature logs have been revised so they are more user friendly and clear and concise instructions are now provided on the temperature logs. If out of range the staff must contact the administrator on call. The external thermometer on the freezer was found to not be functioning properly. An internal thermometer has been placed in the freezer to get accurate temperatures. An electrician arrived on 01/23/2025 and determined the freezer did need a new external thermometer. The electrician took measurements and will provide the facility with a quote the week of 01/27/2025 and an appointment day and time to replace. If out of range the staff must contact the administrator on call. All BHA Technicians have been trained, and attestations have been placed in personnel files. An online/electronic formatted work order log was created for the facility. All staff have access to this log and can put on the log any issues identified within the facility. This log will be monitored daily and an update to corrections needed will be documented daily. This is being monitored by the Director of Facilities Management and the CEO of French
Creek. This was put in place on 1/20/2025. All staff will be trained by Department Managers by 02/07/2025 and attestations will be placed in personnel files. This will be added to orientation and all new hires after 01/31/2025 will be trained in orientation.
|
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.
|
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 eight of twenty-three applicable records.
Staff #1 was hired on September 17, 2024 and still employed. The training was completed on September 30, 2024.
Staff #2 was hired on September 17, 2024 and still employed. The training was completed on October 9, 2024.
Staff #3 was hired on August 29, 2024 and still employed. The training was completed on September 13, 2024.
Staff #4 was hired on August 29, 2024 and still employed. The training was completed on October 1, 2024.
Staff #5 was hired on September 10, 2024 and still employed. The training was completed on November 6, 2024.
Staff #6 was hired on September 23, 2024 and still employed. The training was completed on October 30, 2024.
Staff #7 was hired on September 24, 2024 and still employed. The training was completed on October 10, 2024.
Staff #8 was hired on September 24, 2024 and still employed. The training was completed on October 2, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 5, 2024 annual licensure inspection.
|
Plan of Correction
1. Plan of Correction: As of 01/27/2025 all staff have been trained. New staff will now be trained during the New Hire Orientation on day one going forward on the use of fire extinguishers. Staff will not be able to work on the unit until this training has been completed. The HR Director will track compliance and ensure that all staff are properly and timely trained in the use of fire extinguishers.
2. The HR Director will report in the Monday Management meeting of any employees whose training has or will be lapsing. Staff who do not have active fire extinguisher training will be removed from the schedule until they become compliant with this training. The HR Director will designate a person to report on this requirement in the event she is unable to attend the Monday Management Meeting. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure all staff were trained to perform assigned tasks during emergencies in eight of twenty-three applicable records.
Staff #1 was hired on September 17, 2024 and still employed. The training was completed on September 30, 2024.
Staff #2 was hired on September 17, 2024 and still employed. The training was completed on October 9, 2024.
Staff #3 was hired on August 29, 2024 and still employed. The training was completed on September 13, 2024.
Staff #4 was hired on August 29, 2024 and still employed. The training was completed on October 1, 2024.
Staff #5 was hired on September 10, 2024 and still employed. The training was completed on November 6, 2024.
Staff #6 was hired on September 23, 2024 and still employed. The training was completed on October 30, 2024.
Staff #7 was hired on September 24, 2024 and still employed. The training was completed on October 10, 2024.
Staff #8 was hired on September 24, 2024 and still employed. The training was completed on October 2, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 5, 2024 annual licensure inspection.
|
Plan of Correction
Plan of Correction: As of 01/27/2025 all staff have been trained. New staff will now be trained during the New Hire Orientation on day one going forward on emergencies. Staff will not be able to work on the unit until this training has been completed. The HR Director will track compliance and ensure that all staff are properly and timely trained on emergencies. |
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.
|
Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of thirteen records.
Client #11 was admitted to the residential level of care November 8, 2024 and still a current client. A release of information to another agency was signed by the client on December 4, 2024 but did not indicate purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from June 5, 2024, June 8, 2023, June 16, 2022 and June 11, 2021 annual licensing inspections.
|
Plan of Correction
Plan of Correction: Clinical, Admission and Nursing staff will be trained by their Department Manager to include the purpose on all ROI's by 02/07/2025. The corporate IT department is in the process of modifying the form so that no fields can be left blank. All consents will be audited ongoing daily for completion with a goal of 100%. Attestations will be placed in each employee personnel file that the training received. |
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.
|
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.
This is a repeat citation from the June 5, 2024 annual licensure inspection.
|
Plan of Correction
Plan of Correction: A policy was created on 1/21/2025 regarding the inspection of medication storage areas to include the requirements from the state of Pennsylvania Regulation. This policy was reviewed by management and corporate staff. The Director of Nursing will train all Nursing Staff by 02/07/2025 and obtain attestations that will be placed in personnel files. |
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.
|
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 a consent to release information failing to indicate the purpose of disclosure was submitted and approved by the Department for the June 5, 2024, 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 December 19, 2024 provisional licensure inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 5, 2024 and June 8, 2023 annual licensing inspection.
|
Plan of Correction
(2) Plan of Correction: The CEO is responsible for ensuring plans of correction are followed. On 01/06/2025, the organization appointed an experienced Chief Executive Officer (CEO) to lead the facility in addressing and correcting deficiencies that had previously gone unresolved under the prior executive leadership. 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. |