INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7 - 8, 2023 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 the personnel and training records, the facility failed to ensure that all staff completed 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the required time frame in three of six applicable records.
Staff #3 was hired as a counselor on March 15, 2022 and was still in the position at the time of the inspection. HIV/AIDS training was due to be completed by March 15, 2023 but was not completed until April 26, 2023.
Staff #4 was hired as a counselor on May 31, 2022 and was still in the position at the time of the inspection. TB/STD training was due to be completed by May 31, 2023 but was not completed as of the date of the inspection.
Staff #7 was hired as a counselor on August 24, 2021 and was still in the position at the time of the inspection. HIV/AIDS and TB/STD training was due to be completed by August 24, 2022. The HIV/AIDS training was not completed until January 9, 2023. TB/STD training was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/9/23 Chief Executive Officer educated Human Resource Manager regarding the need to ensure all staff complete 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the required time frame.
The Human Resource Manager completed an audit on 6/9/23 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. No additional negative findings were noted.
The Human Resource Manager will complete a monthly audit for three months to ensure adherence to the standard. 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 quarterly by the Committee of the Whole.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill records, the facility failed to conduct unannounced fire drills at least once per month.
Fire drill records were reviewed from June 2022 - May 2023. Fire drills were not conducted for December 2022, February 2023, March 2023, April 2023, and May 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Plant Operations Manager was educated on 6/9/23 regarding the requirement to conduct unannounced fire drills at least once per month.
The Risk Manager or designee will complete a monthly audit to ensure unannounced fire drills are being completed once per month, with a goal of 100% compliance.
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) (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 documentation of problems encountered.
Fire drill records were reviewed from June 2022 to May 2023. Fire drills documented from June, July, September, October, and November 2022 did not include problems encountered.
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 6/9/23 regarding the requirement to 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.
The Risk Manager or designee will complete monthly audit to ensure fire drill records include documentation of problems encountered, with a goal of 100% compliance.
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) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill records, the facility failed to conduct a fire drill during sleeping hours every 6 months.
Fire drill records were reviewed from June 2022 - May 2023.
A sleeping hour fire drill was done on November 30, 2022 and another was due by May 2023. No other sleeping hour fire drills were conducted.
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 6/9/23 regarding the requirement to conduct a fire drill during sleeping hours at least every 6 months.
The Risk Manager or designee will complete monthly audit to ensure fire drills are being conducted during sleeping hours at least every 6 months, with a goal of 100% compliance.
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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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 one of sixteen clients records.
Client #10 was admitted to residential treatment on May 2, 2023 and discharged on May 30, 2023. The client ' s record included documentation of a disclosure to an agency prior to a release of information being signed by a client. The disclosure was dated May 11, 2023 and the release of information was signed by the client on May 16, 2023.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 16, 2022 and June 11, 2021 annual licensing inspection.
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Plan of Correction
The Clinical Supervisor educated staff on 6/9/23, regarding the requirement to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Facility implemented electronic health records on 6/20/23 to ensure adherence to standards and prevent non-compliance
The Clinical Supervisor completed 100% audit of all client charts on 6/9/23 to ensure an informed and voluntary consent from the client for the disclosure of information was obtained. No additional negative findings were noted.
All current and future clients will sign and complete a release of information prior to any release of information occurring.
The Clinical Supervisor or designee will complete a monthly audit of 30 charts to ensure an informed and voluntary consent from the client for the disclosure of information is obtained and |
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 the purpose of disclosure on an informed and voluntary consent in one of sixteen client records.
Client #10 was admitted to residential treatment on May 2, 2023 and was discharged on May 30, 2023. A release of information to an agency was signed by the client on May 16, 2023 but did not indicate the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 16, 2022 and June 11, 2021 annual licensing inspection.
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Plan of Correction
The Clinical Supervisor educated staff on 6/9/23 regarding the requirement to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record and that the purpose of disclosure has been confirmed in writing. Facility implemented electronic health records on 6/20/23 to ensure adherence to standards and prevent non-compliance.
The Clinical Supervisor completed a 100% audit of client charts on 6/9/23 to ensure an informed and voluntary consent from the client for the disclosure of information included the purpose of the disclosure in writing. No additional negative findings were noted.
The Clinical Supervisor or designee will complete a monthly audit of 30 charts to ensure an informed and voluntary consent from the client for the disclosure of information is obtained and present in the client record and includes purpose of the disclosure in writing, with a goal of 100% compliance to the standard. Oversight of compliance will be monitored quarterly by the Committee of the Whole.
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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 complete an aftercare plan in one of two applicable 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 detox on October 15, 2022 and routine discharged on October 22, 2022. No aftercare plan was documented for this client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Nursing educated nursing staff on 6/9/23, regarding the requirement to have a complete client record on an individual which includes information relative to client's involvement with the project. This shall include aftercare plans for all routine discharges and attempted for all atypical discharges.
Clinical Supervisor educated clinical staff on 6/9/23, regarding requirement to have a complete client record on an individual which includes information relative to client's involvement with the project. This shall include aftercare plans for all routine discharges and attempted for all atypical discharges.
The Director of Nursing and Clinical Supervisor completed an audit of 10 client charts on 6/9/23 to ensure client's involvement with the project includes aftercare plans for all routine discharges and attempted for all atypical discharges. No additional negative findings were noted
The Director of Nursing or designee will complete a monthly audit for three months to ensure adherence to the standard. The goal of the audit will be to ensure that the complete client record includes aftercare plan, if applicable, with a goal of 100% compliance per month. Oversight of compliance will be monitored quarterly by the Committee of the Whole.
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709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and staff interviews, the facility failed to document that work done by the clients at the facility is an integral part of the treatment and rehabilitation plan in seven of seven residential client records.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and staff were educated on 6/9/23 regarding the requirement to have a complete client record on an individual which includes information relative to client's involvement in the project, which includes verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
The Clinical Supervisor completed an audit on 6/9/23 to ensure all work activities were added to client's treatment plans to ensure that work done by the client, including chores or upkeep of grounds at the project is an integral part of his treatment and rehabilitation plan. Any negative findings were immediately corrected
Work activities completed by clients will be added to all client's treatment plan to ensure work done by the client at the project is an integral part of his treatment plan.
The Clinical Supervisor or designee will complete a weekly audit for one month to ensure compliance to the standard. If adherence to the standard is consistently met the Clinical Supervisor or designee will reduce the audit to once per month. The goal of the audit will be to ensure that work done by the client at the project is an integral part of his treatment and rehabilitation plan with a goal of 100% compliance per month. Oversight of compliance will be monitored quarterly by the Committee of the Whole. In the event non-compliance is identified, the clinician will be re-educated and/or receive appropriate disciplinary action.
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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 11, 2021 and June 16, 2022 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 8, 2023 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 11, 2021 and June 16, 2022 annual licensing inspections. Consents to release information not indicating the purpose were again found to be a deficiency in the June 8, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/9/2023, the Chief Executive Officer completed a review of prior plans of correction to the Department from the June 11, 2021, and June 16, 2022, licensing inspections to ensure adherence to the standard.
The leadership team will monitor and review the plans of correction weekly to ensure 100% compliance.
Oversight of compliance will be monitored quarterly by the Committee of the Whole.
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