INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2022 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on three of seven personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee #'s 5, 6, and 7.
Employee # 5 was hired as a counselor on August 24, 2021 and was still in this position at the time of the inspection. Based on a review of employee # 5's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
Employee # 6 was hired as a counselor on October 4, 2021 and was still in this position at the time of the inspection. Based on a review of employee # 6's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
Employee # 7 was hired as a counselor on March 15, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 7's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree. Also, based on employee # 7's resume and transcripts, employee # 7 did not have a qualifying degree for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services has updated counselor's position to reflect change to counselor's assistant for Employee #5,6 and 7. Each counselor's assistant has been assigned to a counselor for supervision until they've reached one full year of clinical experience. Counselor #7 will remain a counselor's assistant until she has completed a qualifying degree or a state board certification. Records of clinical supervision will be maintained by Director of Clinical Services. All clinical new hires transcripts will be reviewed by Director of Clinical Service and Director of Human Resources prior to onboarding to ensure proper credentials and experience. If the facility is unclear of whether clinical team member has the proper credentials and/or experience, the facility will reach out to DDAP licensing specialist. |
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 clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. Stairs were missing guardrails on the detox exit stairs and the stairs from the parking lot to the main entrance.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 11, 2021 annual licensing inspection.
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Plan of Correction
Facility CEO has submitted a work order for installation of replacement railings to be installed. The work order has been approved and railings will be installed to code once materials are received. Director of Facility Maintenance will complete weekly facility rounds to ensure stairwells and railings are maintained. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The bathroom in rooms 227-228 had an excessive amount of paint chipping away from around the shower area. Also, the floor tiles were lifting and raised in the staff bathroom in the detox area.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 11, 2021 annual licensing inspection.
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Plan of Correction
Work orders have been placed for renovations in bathrooms with chipped paint and floor tiles lifting. Director of Facility maintenance has placed "Out of Order" signs are restrooms with lifting tiles until the flooring has been replaced. Chipping paint will be scrapped and repainted until full renovation has been completed. Weekly facility maintenance rounds will be completed by Director of Facility maintenance and turned into Facility CEO. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. The second exit from the 3rd floor file room was locked with a key lock that did not allow for easy access.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Facility Maintenance has removed lock dividing 3rd floor file room to allow for a second egress for both sides of 3rd floor file storage. Director of Facility Maintenance will monitor fire exit access during weekly facility safety rounds and report an deficiencies to the facility CEO. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
The handrail on the lower-level exit and the exit from the kitchen was loose and not well secured.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Facility Maintenance has secured handrail on the lower-level exit from the kitchen.
Director of Facility Maintenance will conduct facility safety rounds weekly and turn his findings into facility CEO. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on one of one applicable client record reviewed, the facility failed to provide documentation of notifying the emergency contact after the client left against medical advice in accordance with facility policy and procedure manual. The facility policy and procedure manual states, "The primary clinician will advise appropriate client contacts (with consent) of the client ' s decision to discontinue treatment. Emergency contact will be contacted at time of discharge and record of contact will be documented in client ' s file."
Client # 11 was admitted on September 16, 2021 and was discharged October 6, 2021. There was no documentation of the emergency contact being notified in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 11, 2021 annual licensing inspection.
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Plan of Correction
Documentation of contact with clients' Emergency Contact upon atypical discharge has been added to Nursing discharge forms. The Director of Nursing will perform chart audit to ensure proper contact to Emergency Contact has been completed. |
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 one of thirteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 8.
Client # 8 was admitted on April 29, 2022 and was still active at the time of the inspection. A letter dated June 6, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 11, 2021 annual licensing inspection.
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Plan of Correction
Confidentiality Training was provided and documented to all staff. The Director of Clinical services will review all letters being sent to other parties prior to them being sent. |
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 one of thirteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure
Client # 13 was admitted on October 27, 2021 and was discharged on November 2, 2021. An informed and voluntary consent from the client for the disclosure of information dated October 27, 2021 to an emergency contact did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 11, 2021 annual licensing inspection.
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Plan of Correction
The Director of Quality and Risk management has provided and documented training in confidentiality and consents. The Director of Quality and Risk will also be conducting chart audits weekly to ensure all consents are properly completed as well as provide immediate correction and training upon errors found. |
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 three of thirteen client records reviewed, the facility failed to provide documentation of medication being provided as prescribed by a physician.
Client # 8 was admitted on April 29, 2022 and was still active at the time of the inspection.
Three medications were prescribed to be taken at 8:30 and 2130. After a review of the facility medication administration records, there was no documentation of the medication being given at both times on:
May 4 and May 25, 2022.
A medication prescribed to be taken at 2130 only was not documented on:
May 4, 2022.
Client # 9 was admitted on May 18, 2022 and was still active at the time of the inspection.
A medication was prescribed to be taken at 8:30 and 2130. After a review of the facility medication administration records, there was no documentation of the medication being given at both times on:
May 19 and May 20, 2022.
A medication was prescribed to be taken at 8:30 and 1730. After a review of the facility medication administration records, there was no documentation of the medication being given at both times on:
May 20, 2022
Client # 11 was admitted on September 16, 2021 and was discharged on October 6, 2021.
A medication was prescribed to be taken at 8:30 and 2130. After a review of the facility medication administration records, there was no documentation of the medication being given at both times on:
May 19 and May 20, 2022.
A medication was prescribed to be taken at 8:30 and 2130. After a review of the facility medication administration records, there was no documentation of the medication being given at both times on:
October 1, 4, 5, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing has provided and documented training to all nursing staff on proper MAR documentation. The Director of Nursing will also conduct chart audits to ensure nursing staff is completing documentation. |