INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 5-7, 2025, 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:
|
Plan of Correction
|
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion for the assessment of staff training needs, overall plan addressing the needs, a mechanism to collect feedback on completed training and an annual evaluation of the overall training plan.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creek has created a new policy in an effort to meet this requirement. The policy outlines how training plans are developed and utilized by employees. This plan described the time frames for training plan completion, assessment of of staff training needs, how to collect training feedback, and the requirements of employee annual traning plan review. This policy was trained on during the 5/22/2025 staff meeting and evidence of this training was placed into employee HR files. On 6/1/2025, The CEO ensured that this trainings were present in employee files. The CEO will ensure that the Human Resources Director establishes training plans upon hire. The HR Director will report during Monday Management Meetings the training plans that were developed for new hires, roadblocks involved in the development of these plans, and/or any plans out of compliance due to employees not following through with trainings. This communication loop will allow the CEO and HR Director the ability to problem solve issues on a weekly basis and identify the staff that need to be removed from shifts due to training plan incompleteness. The first report of training plans to the management team will be completed on 6/9/2025.
|
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.
|
Observations
Based on a review of facility policy and procedures, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients which included an accurate/realistic timeframe for the completion of case consultations.
The facility's policy manual stated that case consultations are to be completed at least every 90 days. The average length of stay, as reported by facility staff on the Data Collection Report Form, is 28 days. The 90 day timeframe documented in the facility's policy manual is not accurate or realistic, as it is outside the average length of stay for the clients at this facility.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The CEO modified the policy titled "Case Consultation". This policy now states that clinical staff will perform case consultations minimally every 3 weeks for all clients. This policy was reviewed and trained on by the CEO during the 5/22/2025 all staff meeting. Signed training was placed into employee files and verified by the CEO on 6/1/2025. The Clinical Director will include into his monthly audits, an audit of case consultations to ensure that the clinicians are meeting the new time frame established. The Clinical Director will be performing chart audits on 80% of all charts for a minimum of 30 days to esnure that the new time frame is being adhered to by clinical staff. The clinical director will meet with any staff member who does not adhere to this time frame and document re-training of this policy in supervision notes moving forward. The quality assurance director has added this item to the monthly audit tracker and each chart will be evaluated monthly to ensure that this requirement is being completed, and completed timely.
|
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.
|
Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of fourteen records.
Client #4 was admitted to the detoxification level of care March 26, 2025 and discharged March 28, 2025. Two releases of information to government agencies were signed by the client on March 26, 2025 but did not indicate purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from December 19, 2024, June 5, 2024, June 8, 2023, June 16, 2022 and June 11, 2021 annual licensing inspections.
|
Plan of Correction
The Release of Information forms for Client#4 were ROI's that should have been completed by our admissions department when the client admitted into treatment. The admissions department will audit admission ROI's within 3 days of each new admission over the next 90 days. The Admissions Director will complete the audits and forward results to the Quality Assurance Director every Friday. ROI's that are missing or incomplete upon admission will be corrected and the staff member will receive retraining. All retraining documents, including evidence of these trainings, will be forwarded to the Human Resources Director to be placed into the employees file. If an employee receives 3 of these corrective trainings within a 6 month period, the employee will be eligible for termination. The Quality Assurance Director will report each Friday in morning management flash meetings the outcomes of the Admission audits and corrective trainings, if there were any, over the next 90 days. The CEO has put an agenda line item on the flash report to ensure that this item is discussed each week. The first audit for admissions will begin 5/26/2025. The first Friday report to management will be due 5/30/2025. After 90 days of weekly audits, and if 100% compliance is achieved, the audit requirement will drop to a monthly audit. In the event that errors are found during the 90 day audit period, the audit will be extended another 90 days until 100% audit results are maintained. One the monthly audit requirement is fullfilled, demonstrating 90 day compliance of 100% completed ROI's, the end date of this audit will be documented in a flash report. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a comprehensive unusual incident policy to include reporting physical assault or sexual assault by staff or a client.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including those incidents of physical or sexual assualt. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO.
|
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop policies and procedures to respond to unusual incidents including selling or use of illicit drugs on the premise.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including those incidents of selling or use of illicit drug use on the premise of French Creen. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO.
|
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop policies and procedures to respond to unusual incidents including death or serious injury due to trauma, suicide, medication error or unusual circumstances.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including deaths or serious injury due to trauma, suicide, medication error of other unusual circumstances. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop policies and procedures to respond to unusual incidents including significant disruption to services due to disaster such as fire, storm, flood, or other occurrence which closes the facility for more than 1 day.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including those incidents that may cause service disruption due to fire, storm, flood, or other occurrences which closes all or part of the facility for a day or more. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop policies and procedures to respond to unusual incidents including theft, burglary, break-in, or similar incident at the facility.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including incidents of theft, burglary, break-in, or similar incident at the facility. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop policies and procedures to respond to unusual incidents including events at the facility requiring the presence of police, fire, or ambulance personnel.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including events at the facility requiring the presence of police, fire, or ambulance personnel. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop policies and procedures to respond to unusual incidents including fire or structural damage to the facility.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including those incidents involving fire or structural damage to the facility. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop policies and procedures to respond to unusual incidents including outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creeks Incident Reporting policy was changed. The new policy combined several policies into one, to improve clarity and communication about our Unsual Incident Reporting. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. This policy clearly outlines French Creeks response to unusual incidents, including outbreak of a contagious disease requiring Centers for Disease Control (CD) notification. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.64(f)(1) LICENSURE Outreach
709.64. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a written plan providing for outreach services including identifying persons in need of project services in the detoxification level of care.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creek modified the policy titled "Detox Services" to include a plan for providing outreach services, including identifying persons in need of project services in the detoxification level of care. This new policy will was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.64(f)(2) LICENSURE Outreach
709.64. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a written plan providing for outreach services including alerting persons and their families to the availability of project services in the detoxification level of care.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creek modified the policy titled "Detox Services" to include a plan for providing outreach services, including alerting persons and their families to the availability of project services at the detoxification level of care. This new policy was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.64(f)(3) LICENSURE Outreach
709.24. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a written plan providing for outreach services including encouraging persons to utilize the service delivery system in the detoxification level of care.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creek modified the policy titled "Detox Services" to include a plan for providing outreach services, including providing for outreach services and encouraging individuals to utilize the service delivery system of the detoxification level of care. This new policy was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.54(d)(1) LICENSURE Outreach Identifying Persons
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(1) Identifying persons in need of project services.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a written plan providing for outreach services including identifying persons in need of project services in the residential level of care.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creek modified the policy titled "Post Discharge Follow Up - Residential Services" to include a plan for providing outreach services, including identifying persons in need of project services in the residential level of care. This new policy was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.54(d)(2) LICENSURE Alerting Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(2) Alerting persons and their families to the availability of project services.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a written plan providing for outreach services including alerting persons and their families to the availability of project services in the residential level of care.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creek modified the policy titled "Post Discharge Follow Up - Residential Services" to include a plan for providing outreach services, including alerting persons and their families of the availability of project services in the residential level of care. This new policy was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
709.54(d)(3) LICENSURE Encouraging Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(3) Encouraging persons to utilize the service delivery system.
|
Observations
Based on a review of the policy and procedure, the facility failed to develop a written plan providing for outreach services including encouraging persons to utilize the service delivery system in the residential level of care.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
French Creek modified the policy titled "Post Discharge Follow Up - Residential Services" to include a plan for providing outreach services, including encouraging persons to utilize the service delivery system in the residential level of care. This new policy was trained on during the all staff meeting on 5/22/2025 by the CEO. Attestation statements were signed by employees and placed into their HR file by the HR Director as proof that they were trained on this new policy. On 6/1/2025 the CEO verified that these statements were put into the HR files. The CEO created a table of contents to identify all the required policies needed by French Creek. The policy set will be reviewed by the CEO semi-annually to ensure that the policy set is complete. The first review occurred on 6/2/2025 by the CEO. |
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.
|
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 a consent to release information failing to indicate the purpose of disclosure was submitted and approved by the Department for the December 19, 2024, June 5, 2024, June 8, 2023, June 16, 2022 and June 11, 2021 annual licensing inspections. Consents to release information not indicating the purpose were again found to be a deficiency in the May 7, 2025 licensure inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
French Creek has initiated several project improvements to ensure that we never leave a line item blank on an ROI. An investigation was performed and it was identified that the ROI's were from a new staff. This raised the opportunity to improve our onboarding training to new hires, supervision of documentation of new hires, and management of on going audits. French Creek has adopted a new training requirement for new staff. The admissions department will audit each file within 24 buisness hours of admission to ensure that all ROI's were completely filled out. This started on 5/25/2025. Additionally, our IT department is working on creating the form in our EMR to be unable to be saved unless all fields are completed. Our IT department estimates that this change will occur by 6/12/2025. In the meantime, the Admissions Director will audit 100% of all new admission charts for complete ROI's within 24 buisness hours of the clients arrival and report findings in morning flash meetings with management. The Quality Assurance Director will continue to audit all ROI's weekly. Instead of submitting her audits only via written report, she will report her findings each day in morning flash meetings to the management team. ROI's that are found to be incomplete will result in documented retraining of the employee and a Performance Improvement Plan placed into the employees file. If an employee has 3 or more missed ROI's in a 90 day period the employment status will be reviewed with HR to determine if termination is warranted. The CEO will ensure that all audits and tabulations of finds are maintained each week starting 6/6/2025. Summary of findings will be reported in the monthly Committee of the Whole meeting by the Quality Assurance Director. |