INITIAL COMMENTS
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This report is a result of on-site technical assistance and complaint investigations conducted on January 23, February 4-5 and February 10, 2025 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility in good repair at all times for the safety and well-being of residents, employees and visitors.
At the time of the onsite complaint investigation, one of the detox bathroom doors was observed to have a broken lock. The other detox bathroom door was found to be recently repaired; however, the door latch plate was coming loose and had only one visible screw left. In addition, there was a TV cable cord found in the male lounge that had a missing cap, exposing a sharp metal wire.
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Plan of Correction
By 4/10/2025, all staff will be re-educated by the Director of EOC or designee to immediately remove broken items from the unit when identified. Training will be completed by 4/10/2025. In the event staff are unable to complete training by 4/10/2025, their time clock access will be de-activated, and the employee will be unable to work until training is completed. Training will be added to the new hire orientation.
Sustainability Plan: The Director of EOC will be responsible for conducting weekly environmental rounds to ensure the facility is in proper working order. The Director of EOC shall report on compliance with completed work orders, with a goal of 95% compliance per month. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board. Audits shall remain ongoing at this time.
In the event of non-compliance, the employee(s) shall be re-educated in writing which will be evident in the employee's HR file, if they fail to report an item that is a hazard or safety concern.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to refrain from the use of heaters that are not permanently mounted or installed.
A portable spacer heater was observed in the administrative office where the auditors were located.
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Plan of Correction
On 03/20/2025, the CEO provided re-education to the leadership team related to removing space heaters from the facility. Leadership attested to understanding in writing.
By 4/10/2025, all staff will be re-educated by the Director of EOC or designee related to the restriction of space heaters within the facility. Training will be completed by 4/10/2025. In the event staff are unable to complete training by 4/10/2025, their time clock access will be de-activated, and the employee will be unable to work until training is completed. Training will be added to the new hire orientation.
Leadership Rounds are done daily - 7 days a week. Leadership has divided this task up amongst Directors. Each director now takes a day to complete the Leadership Rounds. This prevents one director from missing something. A fresh pair of eyes are looking at compliance and facility items each day. All space heaters have been removed from the facility by the CEO and Milieu Manager. Leadership Rounds now includes ensuring that none are found moving forward, each day.
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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 instruct all staff in the use of fire extinguishers upon staff employment.
Staff #1 was hired as the chief executive officer on January 6, 2025. Staff #1 did not have documentation of fire extinguisher training until January 14, 2025.
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Plan of Correction
On 3/10/2025 the Director of HR (DHR) updated the facility's new hire orientation (NEO) to include completion of fire extinguisher training on day one. In addition, a checklist was developed that outlines required training elements that are reviewed and signed off by the DHR for each day of NEO.
On 3/20/2025 the Corporate Director of Quality and Data Management provided re-education to the CEO, DHR, and Director of EOC related standard 705.10 (c) (4) P P139
"Fire safety" and the requirement to complete fire extinguisher training upon employment. The CEO, DHR, and Director of EOC attested to understanding in writing.
Sustainability Plan: The DHR is responsible for ensuring that fire extinguisher training is completed during the new hire orientation. The DHR will audit 100% of new employee files to ensure fire extinguisher training is completed by day one of NEO, with a goal of 100% compliance for 90 consecutive days. Thereafter, with sustained compliance, the audit will remain ongoing but may be decreased to a review of 50% of new employee files. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board.
Staff will not be scheduled to work until fire extinguisher training is completed. In the event of non-compliance, the Director shall be re-educated in writing which will be evident in the employee's HR file.
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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 that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Staff #1 was hired as the chief executive officer on January 6, 2025. Staff #1 did not have documentation of emergency training until January 21, 2025.
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Plan of Correction
On 3/10/2025 the Director of HR (DHR) updated the facility's new hire orientation (NEO) to include completion of emergency training on day one. In addition, a checklist was developed that outlines required training elements that are reviewed and signed off by the DHR for each day of NEO.
On 3/20/2025 the Corporate Director of Quality and Data Management provided re-education to the CEO, DHR, and Director of EOC related standard 705.10 (d) (3) P P145 "Fire safety" and the requirement to complete emergency training. The CEO, DHR, and Director of EOC attested to understanding in writing.
Sustainability Plan: The DHR is responsible for ensuring that emergency training is completed during the new hire orientation. The DHR will audit 100% of new employee files to ensure emergency training is completed by day one of NEO, with a goal of 100% compliance for 90 consecutive days. Thereafter, with sustained compliance, the audit will remain ongoing but may be decreased to a review of 50% of new employee files. Results will be reported
monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of policy and procedures, the faciliy failed to prepare, annually update and sign the policy manual.
The most recent policy and procedure manual was requested. A 2023 manual was provided. It was reported to DDAP that facility staff were working on an electronic version of the policy and procedure manual; however, it was not complete or approved yet. There was no documentation that the existing policy and procedure manual was updated and signed by the director in 2024.
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Plan of Correction
On 3/14/2025, the CEO completed a review of the facility's policy and procedure manual and approved it in writing.
Sustainability Plan: An annual quality indicator will be added to the facility's Governing Board agenda to ensure policies and procedures are reviewed and approved in writing by the CEO prior to review by the board.
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709.34 (c) (3) 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:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a physical plant inspection, staff interview and a review of administrative documentation, the facility failed to report a disruption of services that resulted in a partial closure of the facility which lasted more than one day.
A complaint was filed with the Department on February 10, 2025 with allegations that there was no heat in the building. An onsite investigation took place that same day. It was documented that the furnace was not operable for two days, starting on January 8, 2025 and twelve clients were relocated to a hotel. There was no documentation that a written unusual incident report was filed with the Department within 3 business days.
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Plan of Correction
On 3/20/2025, the Corporate Director of Quality and Data Management provided education to the CEO and QRD related to self-reporting disruptions in services to the Department and compliance with 709.34 (c) (3) L 0361. Both the CEO and QRD attested to understanding in writing and agreed that any future disruptions in services will be self-reported timely to the Department as outlined in the regulation.
Sustainability: The QRD is responsible for ensuring self-reporting related to disruption in services is completed timely as outlined in 709.34 (c) (3) L 0361 with a goal of 100% compliance per event. Results will be reported monthly to the COWs and quarterly to the facility's Governing Board for oversight.
In the event non-compliance is identified, the QRD shall be re-educated in writing by the CEO, and upon notification the self-report shall be submitted by the facility as soon as possible.
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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 and client records, the facilty failed to file a written unusual incident report with the Department within 3 buisness days following an unusual incident involving an event at the facility which required the presence of ambulance personnel.
Events occurred at the facility on January 11 & 15, 2025 which required the presence of an ambulance. There was no documentation that either of these events were reported to the Department.
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Plan of Correction
On 3/4/2025, the facility identified documentation errors in two incident reports, where "ambulance" was recorded as the mode of transportation for clients instead of "non-emergent transportation."
On 3/20/2025 the Corporate Director of Quality and Data Management provided re-education to the CEO and QRD pertaining to incident reporting as it relates to accuracy of events within the facility and documentation. Both the CEO and QRD attested to understanding in writing.
All staff were trained in documentation and attestestations of these were received on 4/1/2025. Training included importance of accurate and clear documentation. Quarterly documentation trainings will occur as standard practice for FC. Trainings will occur either by the Clinical Director or CEO. All records that require emergency services are now being reviewed by the Quality Assurance Director. These charts are being specifically reviewed for accuracy of content, quality of documentation, and clarity of information.
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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 & client interviews, client grievances and unusual incidents, it was found that gross incompetence, negligence and/or misconduct was present at the facility during a complaint investigation that occurred on February 4-5, 2025.
An alleged sexual assault took place at the facility on January 22, 2025. Facility staff reported to DDAP that an internal investigation was conducted and there was no evidence that a sexual assault took place. There was documentation in the client record that the client was taken to the hospital and a rape kit was completed. The rape kit results indicated that physical evidence was present at the time the client was assessed.
Documentation of a traffic citation for expired state registration was reviewed. The facility was issued a citation on January 27, 2025. It was documented that the facility's vehicle registration had expired August 30, 2024.
There were reports of multiple motor vehicle accidents that occured with the facility vehicle, one resulting in injuries requiring staff to be off of work for more than one month.
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Plan of Correction
On 03/10/2025, the Chief Executive Officer (CEO) spoke with the lead detective of the case who reported any samples from the SANE examination have been sent to the lab for analysis and as of date, no results have been confirmed. The detective reported results could take 5-6 months to be returned.
On 03/10/2025, the clinician on record reported that the information documented in the client's chart regarding the rape kit results was solely provided by the client, and that the hospital where the examination took place had not communicated that information. An opportunity for improvement in medical record documentation was identified, and a clarifying statement was obtained from the clinician regarding this matter. As of this date, French Creek has no evidence that a sexual assault has taken place.
On 3/20/2025, the identified clinician was provided re-education by the CEO regarding the significance of accurately recording information in the medical record. Additionally, the clinician was instructed to thoroughly document the source of any information that is reported or alleged by clients or others.
By 4/10/2025, all direct care staff responsible for entering medical record documentation will be re-educated by the CEO on the importance of ensuring the accuracy and factuality of information in the chart. Additional instructions will be provided on how to properly document the source of any information reported or alleged by clients or others. Training will be completed by 4/10/2025. In the event staff are unable to complete training by 4/10/2025, their time clock access will be de-activated, and the employee will be unable to work until training is completed. Training will be added to a new hire orientation for direct care staff.
Sustainability Plan: The Director of Quality and Risk Management (QRD) will audit 100% of medical record entries related to facility incidents to ensure accurate and factual documentation is present in the chart. Audits shall remain ongoing and reviewed/clarified with this writer and department leaders when concerns are identified.
Results of the audit will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board who maintains oversight of the facility. In the event of non-compliance, the employee will be re-educated in writing which will be evident in their HR file.
The CEO will provide quarterly staff trainings to direct care and nursing staff on the following:
1) Client Observations
2) What to do in the event of a rape/sexual assault allegation
3) Boundaries Training
These trainings will address the importance of client observations, how to keep clients safe and what to do when a client reports a sexual concern. The first series of these trainings will take place 5/1/2025. The second series will be held on 9/11/2025. Lastly, the 3rd will be held early due to client's increase of depression during the holiday season. The 3rd training will be done December 11th, 2025. These trainings will be done every 4 months thereafter by the CEO.
French Creek has also increased observations of all clients on its co-ed detox unit (floor 1) as of 4/14/2025. (floor where this event allegedly has occurred) Observations on this unit have increased to 20 minutes rather than 30 minutes for detox clients. This change has provided increase staff presence on this co-ed unit which has increased safety of all clients.
On 2/5/2025, the CEO initiated a new process to ensure that vehicle registrations are renewed prior to expiration. A list of vehicles and registration expiration dates was developed, and renewal dates have been added to the CEO and the Director of Environment of Care's (EOC) work calendars. In addition, new monthly checks were implemented on each vehicle, including the inspection of the registration.
Sustainability Plan: An annual quality indicator will be added to the COWs committee for oversight to ensure vehicle registration is renewed timely for each vehicle operated by the facility. Compliance will be reported annually to the Committee of the Whole (COWs) and Governing Board who maintain oversight of the facility.
In the event non-compliance is identified, the Director of EOC shall be re-educated in writing by the CEO, and the vehicle will not be operated until registration is up to date.
On 3/20/2025, the Corporate Director of Quality and Data Management provided education to the leadership team to ensure that medical treatment services must be offered to both staff and clients involved in company vehicle accidents, regardless of fault.
The DHR will be responsible for ensuring that medical treatment is offered to staff, while the DON will be responsible for ensuring medical treatment is offered to clients involved in company vehicle accidents.
Sustainability Plan: The QRD will add a new quality indicator to the facility's Committee of the Whole (COWs) to ensure that medical treatment is consistently offered to both clients and staff involved in company vehicle accidents. The goal is to achieve 100% compliance for each event. Results will be reported monthly to the Committee of the Whole (COWs) and quarterly to the Governing Board who maintains oversight of the facility.
In the event non-compliance is identified, the Director will receive written re-education that will be documented in the employee's HR file and upon notification, when possible medical treatment will then be offered to the staff or client involved in the accident.
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