INITIAL COMMENTS
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This report is a result of on-site provisional license follow-up inspections and a complaint investigation conducted 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 to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. No deficiencies were identified during this inspection and no plan of correction is required.
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Plan of Correction
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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 makes documentation difficult to locate. In addition, the nursing schedules for September 2024 were unable to be retrieved, client lists including admission/discharge dates, level of care and nature of discharge were difficult to generate and there were no auditor logins, requiring auditors to frequently request staff assistance.
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Plan of Correction
Plan of Correction: The facility utilizes HCS as its EMR. French Creek is creating a training manual that auditors can utilize to help them navigate our system. This manual has been started and due to be completed on 2/17/2025. This manual will detail how an auditor can pull reports, such as admission dates, discharged clients, client demographic information, and discharge summaries to name a few. Auditors will be given onsite access to our EMR system from a member of the upper management team who will give the auditor a user name and password for the day - allowing them uninterrupted access during their audit. The manager who gives this information to the auditor will inform the CEO of the allowance that was given. At the end of the day, the personnel will notify tech support to reassign a new password to ensure ongoing confidentiality.
On going training of staff has and will be occurring regarding improving documentation, consistencey and accuracy of documentation. A clinical documentation handbook is being developed to ensure that staff are uniformally using the EMR in their department with their documentation. The completion date for the clinical documentation handbook is 2/18/2025.
Nursing schedules are updated each week by the Director of Nursing and are now located on our shared drive. Our Director of Nursing reviews schedules weekly and the CEO will ensure that schedules are posted each week. This procedure was implemented on 1/20/2025.
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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 #3 was admitted to detox level of care on December 7, 2024 and discharged on December 10, 2024.
Verbal orders for 22 medications were documented on December 7, 2024 at 13:00. Written authentication by a physician or authorized medical professional was documented on December 9 at 8:41 AM.
Verbal orders for two medications were documented on December 9, 2024 at 11:00 and 17:03. Written authentication by a physician or authorized medical professional was documented on December 13, 2024 at 16:18.
Client #4 was admitted to detox level of care on December 2, 2024 and transferred to residential treatment on December 9, 2024.
Verbal orders for 17 medications were documented on December 2, 2024 at 16:28. Written authentication by a physician or authorized medical professional was documented on December 5, 2024 at 17:40.
Verbal orders for six medications were documented on December 4, 2024 at 10:46. Written authentication by a physcican or authorized medical professional was documented on December 5, 2024 at 17:40.
Verbal orders for two medications were documented on December 7, 2024 at 7:24 and 18:10. Written authentication by a physician or authorized medical professional was documented on December 9, 2024 at 8:52 AM.
Client #5 was admitted to detox level of care on November 8, 2024 and transferred to residential treatment on November 14, 2024.
Verbal orders for 16 medications were entered on November 8, 2024 at 20:35. Written authentication by a physician or authorized medical professional was documented on November 11, 2024 at 7:44 AM.
Client #7 was admitted to detox level of care on November 15, 2024 and transferred to residential treatment on November 21, 2024.
Verbal orders for 20 medications were entered on November 15, 2024 at 21:50. Written authentication by a physician or authorized medical professional was documented on November 17, 2024 at 14:48.
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Plan of Correction
Plan of Correction: The Director of Nursing trained the Medical Staff on 01/22/2025 and provided attestations that they understand the regulation of signing detox orders within 24 hours and residential orders within 72 hours. The Director of Nursing will audit orders daily and report on any deficient order during daily Flash Meetings with management. Saturday and Sunday orders will be reviewed by the DON or designee over the weekend . The medical staff will be contacted to sign any orders prior to becoming late. |
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, physical plant inspection, policy and procedures, staff interview, client grievances and unusual incidents, it was found that gross incompetence, negligence and/or misconduct was present at the facility during a complaint investigation and provisional follow up inspection that occurred on December 17-19, 2024.
There was a total of one hundred sixty eight client grievances between September 1 - December 17, 2024. Of these, nine were sexual in nature. Fourteen were medication or nursing related.
Upon arrival at the facility, the auditor found the front door to be propped open. The auditors were able to gain access without assistance from facility staff. Once in the facility, there were no staff available. The auditors asked the people that were present (clients) where the staff were and no one seemed to know. After waiting several minutes, staff arrived.
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Plan of Correction
Plan of Correction:
Action 1: French Creek is dedicated in reducing clients complaints. In response to this, French Creek has created a time on the client schedule called "Coffee with the CEO." Monday - Friday from 9:30am - 10:00am clients can voice any concerns and problem solve with upper management. In the event that the CEO is out, a member of upper management will still be available to clients. This started 2/3/2025.
Action 2: Client forms were modified to help clarify and streamline communication. A complaint, grievance, and positive feedback form was created for clients. These are reviewed with management daily. French Creek understands that complaints and grievances are all concerns, and French Creek has trained all upper management in this philosophy. In the event that a complaint or concern violates a client's right, a formal grievance process will be initiated and documented as such.This has been in place since 2/13/2025.
Action 3: French Creek has modified its evidence binder to include maintaining information on all complaints. This means that French Creek has improved it's documentation of follow through, action plans, and systems that may have been put in place in response to client concerns. This is being done on all concerns as well as grievances. This has been completed as of 2/3/2025.
With respect to the finding regarding the front door the facility has created an alternative entrance for visitors to separate from the client entrance. These doors have been identified with signage. Visitors will ring a buzzer at their new entrance door and staff will promptly greet them at the door where they will have the visitor sign in. The buzzer rings throughout floor 1 where there is always staff. New parking lot signs and door signs were put up on 2/7/2025.
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