INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 5, 25-26, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, French Creek Recovery Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of staff schedules and staff interview and the Staffing Requirements Facility Summary Report, the facility failed to provide one primary care staff during primary care hours.
Licensing alert 3-02 defines primary care staff as the group of individuals, including clinical supervisors, counselors, physicians, physician ' s assistants, psychologists, registered nurses and licensed practical nurses who provide primary care services and those individuals who are responsible for developing and implementing the treatment plan. In addition, for the detoxification activity, primary care hours are 24 hours a day, seven days a week. Staffing levels of primary care staff must be maintained for each shift, 24 hours each day. These designated staff may not have any duties other than in the detoxification unit.
It was determined that there was only one primary care staff, a nurse, present for the following times: March 24th from 12:00 AM - 8:00 AM and 8:00 PM - 12:00 AM with a detox census of 4. March 25th from 12:00 AM - 7:00 AM with a detox census of 2, March 26th from 12:00 AM - 8:00 AM and 3:00 PM - 12:00 AM with a detox census of 2, March 27th from 12:00 AM - 8:00 AM and 3:00 PM to 12:00 AM with a detox census of 3, March 28th from 12:00 AM - 8:00 AM and 11:00 PM - 12:00 AM with a detox census of 4, March 29th 12:00 AM - 8:00 AM and 12:00 PM - 12:00 AM with a detox census of 4, and March 30th from 12:00 AM - 8:00 AM and 3:00 PM - 12:00 AM with a detox census of 3.
It was determined that there were no primary care staff for the following times: June 3rd from 12:00 AM - 6:30 AM and 11:00 PM - 12:00 AM with a detox census of 2. June 5th from 1:00 AM - 6:30 AM and 11:00 PM - 12:00 AM with a detox census of 2, June 8th from 11:00 PM - 12:00 AM with a detox census of 4, June 9th from 12:00 AM - 6:30 AM and 11:00 PM to 12:00 AM with a detox census of 4, June 10th from 12:00 AM - 6:30 AM with a detox census of 4 and June 11th from 2:00 AM - 6:30 AM with a detox census of 3.
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Plan of Correction
French Creek Recovery Center will increase staffing by hiring primary care staff to ensure the client/staff ratio of 7:1 requirement is met for detox clients. Hiring primary care staff has begun and will be completed by (8/31/24). Nursing will monitor the client census and complete schedules to ensure that the 7:1 ratio is maintained. French Creek recovery will temporarily pause accepting detox clients on 8/6/2024 until enough primary care staff have been hired to meet the client/staff ratio of 7:1. |
709.26 (b) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(4) Disciplinary actions.
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Observations
Based on a review of personnel records and staff interviews, the facility failed to document personnel disciplinary actions.
Staff #5 was hired as a support staff on December 5, 2023. A client grievance was submitted to management staff on April 5, 2024, alleging inappropriate behavior by staff #5. It was documented that the issue was sent to the Human Resources department. There was no documentation of disciplinary action or supervisory session in staff record #5.
Staff #2 was hired as a support staff on February 12, 2024. Staff #2 was terminated for gross misconduct on May 8, 2024. The termination documentation states that investigation details can be found in the employee ' s personnel record; however, there was no documentation regarding the incident investigation in staff record #2.
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Plan of Correction
: Director of Human Resources to undergo a retraining on maintaining proper records by 8/16/24 and documentation will be placed in HR Director File.
Monthly audit of HR records to be completed by CEO to ensure all personnel disciplinary actions are complete, accurate and properly documented in said employee record. Audit to begin August 2024 with a goal of 100% compliance
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records and administrative documentation, the facility failed to develop a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives. The facility ' s electronic recordkeeping system is not being used uniformly by all staff. Documentation is difficult to locate and is not always in the same location.
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Plan of Correction
Staff will be trained by 8/16/24 on the process for entering documentation into the electronic medical record to ensure usage of the electronic medical record is uniform.
Monthly audit will be conducted by the Director of Nursing or designee to ensure documentation into the electronic medical record is being entered accurately and in a uniform manner in order to ensure efficient retrieval of data needed to measure the projects stated goals and objectives. All findings will be reported in the Monthly Committee of Whole, audit to begin August 16, 2024 with a goal of 100% compliance
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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 a review of client records, the facility failed to document written authentication of verbal medication orders by a physician or other medical professional authorized by State and Federal Law to prescribe medication within the required timeframe, 24-hours for detoxification and 3 business days for inpatient rehabilitation.
Client #1 was admitted to inpatient rehabilitation on June 12, 2024, and was an active client at the time of the investigation. Two verbal orders were obtained for medication on June 12, 2024. Written authentication of the verbal orders was due to be documented by June 17, 2024. The documentation of written authentication was documented on June 18, 2024.
Client #8 was admitted to inpatient rehabilitation on March 4, 2024, and discharged on April 10, 2024. A verbal medication order was obtained on February 5, 2024. Written authentication of the verbal orders was due to be documented by February 8, 2024. The documentation of written authentication was documented on February 23, 2024. Another verbal medication order was obtained on April 2, 2024. Written authentication of the verbal orders was due to be documented by April 5, 2024. The documentation of written authentication was documented on April 8, 2024.
Client #9 was admitted to inpatient rehabilitation on May 29, 2024, and discharged on June 18, 2024. A verbal medication order was obtained on May 31, 2024. Written authentication of the verbal orders was due to be documented by June 5, 2024. The documentation of written authentication was documented on June 18, 2024.
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Plan of Correction
French Creek Recovery Center will ensure that when a verbal order for medication is provided authentication shall occur within the 24-hour time, or when appropriate based on level on care within 3 business days. The CEO spoke with the Medical Director on (8/6/24) and provided him with training on the state regulations. The Medical Director spoke with the rest of the medical staff on the state regulation. The Quality Manager will review charts daily to ensure orders have been signed within the appropriate timeframes. Status on order authentication will be reported in daily morning meetings and the facility CEO will coordinate with the medical team when needed to ensure orders have been authenticated within required timeframes. |
709.32 (c) (1) (i) - (ii) 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:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of client records, administrative documentation and policy and procedures, the facility failed to follow their Medication Administration and Monitoring of Medication Effects Policy, which states medications will only be administered to clients to whom they have been prescribed and medications are not given without a physician ' s order. In addition, the facility failed to limit medication administration to those individuals permitted by Pennsylvania law.
Client #1 was admitted on June 12, 2024, and was an active client at the time of the investigation. The physician ordered a medication for the client on June 12, 2024. On June 13, 2024, the nurse discontinued the physician ' s order, entered another order for a different medication and administered it. The June 13th order was not verified by a physician and the nurse is not permitted to administer medication without a valid physician order.
Client #3 was admitted on April 11, 2024, and discharged on May 9, 2024. A verbal order for a medication was documented on May 6, 2024, at 19:13. The medication was administered by nursing staff on May 6, 2024, at 19:14. At the time of the onsite investigation, the medication was observed to be in the medication storage area. At the time of the onsite investigation, client #3 ' s medication was found in the medication room.
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Plan of Correction
The Director of Nursing or designee will retrain all Nursing Staff on the Medication Administration and Monitoring of Medication Effects Policy by (8/16/24). The Director of Quality began conducting weekly audits of medication passes to verify the nursing staff is following the policy. The Director of Quality will report any medication errors in the daily meeting and monthly in Committee of Whole. |
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 client records, physical plant inspection, policy and procedure manual and staff interview, the facility failed to follow their Medication Storage policy. The facility policy states that all medications are disposed of within 7 days of a client discharging, if not, taken with them at the time of discharge.
Client #3 was admitted on April 11, 2024, and discharged on May 9, 2024. At the time of the onsite investigation, client #3 ' s medication was found in the medication room.
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Plan of Correction
The Director of Nursing or designee will retrain all Nursing Staff on the Medication Storage Policy by (8/16/24). The Director of nursing or designee will audit the medication fridge and carts daily to verify that medications are being destroyed within the 7 days of the clients discharge as the policy states if the client does not take the medication with them. The results of the daily med room audit will be reporting in daily morning meetings. |
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 a review of client records, the facility failed to administer client medications as prescribed.
Client #1 was admitted on June 12, 2024, and was active at the time of the investigation. A medication was ordered by the physician on June 12, 2024, that stated the medication was to be taken three times per day. The client did not have the medication as prescribed on June 13, 14, 15, 16, 17, 18, 19, 20, 22, 23 and 24, 2024.
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Plan of Correction
The Director of Nursing or designee will educate nursing staff on administering medications as prescribed, and the proper documentation for unadministered medication on the MAR by 8/16/24. Staff will sign attestation forms acknowledging the education/training they received. The Quality Manager will monitor MARs daily and report in daily morning meeting. |
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 unusual incidents, the facility failed to report an event at the facility requiring the presence of police, fire or ambulance personnel to DDAP within 3 business days, as required.
It was documented that client medical events that required the presence of ambulance personnel occurred on March 11 and March 19, 2024. There was no documentation that these events were reported to DDAP.
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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 and Quality Director will submit incidents to DDAP that day. CEO will verify by next day that any previous day incidents have been submitted to DDAP. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan with the client that included the type and frequency of services.
Client #2 was admitted on March 7, 2024, and discharged on April 11, 2024. A treatment plan was developed on March 7, 2024; however, it did not include documentation of the type and frequency of services.
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Plan of Correction
Clinical staff will be re-educated on the clinical requirement of documentation by 8/16/24. French Creek Recovery Center will ensure that treatment type and frequency is documented in the individual treatment plan of all residents. The Quality Manager will audit charts on a weekly basis and follow up with the Director of Clinical Services on any outliers. French Creek Recovery Center Leadership will review findings on a weekly basis and report each month to the Committee of Whole. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling to clients on a regular and scheduled basis.
Client #2 was admitted on March 7, 2024, and discharged on April 11, 2024. There was no documentation that individual counseling was provided to the client during her treatment episode at the facility.
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Plan of Correction
Clinical staff will be re-educated on the clinical requirement of documentation by 8/16/24. Monthly Audit of client charts to be completed by the Clinical Director to ensure that all individual and group counseling notes are included in the medical records. Audit to begin August 2024 with a goal of 100% compliance. Disciplinary action will be taken on any counselor who continues to be below the standard of care of 90% compliance. |
709.17(a)(4) 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:
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
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Observations
Based on a review of client and personnel records, policy and procedures, staff interview, client grievances and unusual incidents and staff timesheets, it was found that gross incompetence, negligence and/or misconduct was present at the facility during complaint investigations that occurred on June 5, 25 and 26, 2024.
The facility failed to provide adequate support and primary care staff to ensure efficient and safe operation of the facility. This is evidenced by the facility being out of compliance with the client/staff ratio and no primary care staff coverage for the detoxification activity for periods of time.
There was a total of twelve client grievances between March 17 - April 10, 2024, that included allegations of sexual impropriety. There was either no documentation or partial documentation of facility investigation.
The facility failed to provide client medications as prescribed, failed to follow facility policy and State Law for medication administration and storage. There was a total of fourteen client grievances reviewed regarding medication from January 26 - May 24, 2024. It was alleged that a verbal order was not documented by nursing staff that led to a medical emergency requiring a call to 911 and treatment at the hospital.
There was a total of three incident reports regarding physical assault between March 24 - May 12, 2024, that were not reported to the Department. In addition, there were two incidents occurring on March 11 and 19, 2024 that involved the presence of ambulance personnel that were not reported to the Department. One of these assaults, occurring on April 9, 2024, resulted in one client being arrested and the other requiring emergency medical services.
There was a total of six incidents between January 19 and April 4, 2024, that involved illicit drugs on facility grounds.
There were five incidents of alleged sexual misconduct by staff for the time period of March 17 - June 21, 2024.
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Plan of Correction
French Creek Recovery Center will increase staffing by hiring primary care staff to ensure the client/staff ratio of 7:1 requirement is met for detox clients. Hiring primary care staff has begun and will be completed by (8/31/24). Nursing will monitor the client census and complete schedules t/o/ ensure that the 7:1 ratio is maintained. French Creek recovery will stop accepting detox clients on 8/6/2024 until enough primary care staff have been hired to meet the client/staff ratio of 7:1. The Quality Manager was trained on the proper documentation of investigations by the Corporate Director of Quality. The Quality Manager was also trained on complaint and grievance policy and procedure. All staff will be retrained by (8/16/24) on boundary violations and sign an attestation that they received this training. The Director of Nursing or designee will retrain all Nursing Staff on the Medication Administration and Monitoring of Medication Effects Policy by (8/16/24). The Director of Quality began conducting weekly audits of medication passes to verify the nursing staff is following the policy. The Director of Quality will report any medication errors in the daily meeting and monthly in Committee of Whole. The CEO will train the Quality Manager on the 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 |
709.17(a)(8) 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:
(8) Mistreating or abusing individuals cared for or treated by the facility.
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Observations
Based on a review of client and personnel records, policy and procedures, staff interview, client grievances and unusual incidents and staff timesheets, the facility was found to have mistreated and/or abused individuals cared for or treated by the facility during complaint investigations that occurred on June 5, 25 and 26, 2024.
It was alleged that on June 4, 2024, a client medical emergency occurred on facility grounds. It was reported that the nursing staff would not open the door for support staff to assist with the client medical emergency.
It was documented that a counselor was terminated on June 21, 2024, for boundary violations when he offered a female client a safe space to " release her pent-up sexual frustrations " in his office while he turned his back.
It was documented that a support staff was terminated on May 8, 2024. for gross misconduct in which further details were not documented in the personnel record.
It was documented on a client grievance dated April 5, 2024, that a support staff, that is still employed, was showing inappropriate content to clients. There was no internal investigation or disciplinary action as of the date of the onsite DDAP investigation.
It was documented that on March 19, 2024, a support staff was sent home from work after receiving multiple client grievances alleging that he was sharing his personal cell phone number, gifting cigarettes, hiding in female client ' s closets and watching female clients change. He quit employment at the facility on March 22, 2024. The internal investigation documentation consisted of an interview with the support staff, who denied the allegations, and permitted to return to work. No further investigation into the matter was documented in the support staff ' s personnel record.
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Plan of Correction
POC: 1) All staff will be retrained on emergency procedures and protocols by 8/26/24, upon completion of training attestation of completion will be signed and maintained in personnel file.
2) Client grievance process was redesigned to ensure adherence to standards with an expectation of resolution within 72hours, staff has been trained and clients educated to process. In daily leadership meeting all grievances are reviewed for progress towards resolution and next steps, with records kept in binder with Quality Improvement Director.
3) All staff will receive boundary training by 8/16/24, upon completion of training, attestation of completion will be signed and maintained in personnel file.
4) Facility HR Director to be retrained on internal investigation procedures by 8/16/24, upon completion of training, attestation of completion to be signed by both parties and maintained in personnel file.
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