INITIAL COMMENTS
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This report is a result of on-site complaint investigations conducted on July 30 -August 1, 2024 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.
A physical plant inspection was conducted on July 30, 2024. At the time of the physical plant inspection, the walk-in freezer, one clothes dryer, two clothes washers, the dishwasher and the juice machine were not functional.
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Plan of Correction
On 8/9/24 the non-functioning washer and dryers were removed. All washers and dryers are now industrial grade. The CEO will monitor daily during rounds that all washer and dryers are functioning properly. An electrician was onsite on 08/08/2024 and checked proper wiring for the walk-in freezer. French Creek Recovery Center has reached out to local Refrigeration Service who will be onsite the week of 8/12/24 to get the freezer assessed and repair scheduled. French Creek Recovery has reached out to corporate office who is getting bids to replace the dishwasher. French Creek Recovery Centers Corporate Office is working with US Foods to obtain a new juice machine for the facility. The nonfunctioning machine has been removed and the facility is getting drinks for the clients locally until the new juice machine arrives. |
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.
A physical plant inspection was conducted on July 30, 2024. At the time of the inspection, the bathroom located on the second floor at the top of the steps was found to be screwed shut and marked " out of order until further notice. "
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Plan of Correction
: Licensed Plumber arrived onsite and inspected pipes in the bathroom on 08/07/2024. Plumber reported he can fix the issue and fixed the leaking issue on 08/09/2024. French Creek is currently getting bids to update the tub with a shower and tub combo with a goal of having the project set up by 08/31/2024. Going forward anytime a leak is discovered that cannot be fixed by internal maintenance staff a plumber will be contacted within 12 hours to address the issue. The CEO will complete daily rounds to ensure no bathrooms are out of service. |
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 a review of facility policy and procedures, the facility failed to follow their discharge policy in two of four client records. Per the facility Discharge Planning and Process policy, transportation to a safe location is offered and available, this may include transport to another local transportation center, or local convenience store, gas station. If clients refuse, this information is documented in the medical record/incident report as applicable.
Client #3 was admitted on July 2, 2024, and discharged on July 6, 2024. There was no documentation that transportation was offered or refused in client record #3.
Client #6 was admitted on June 18, 2024, and discharged on June 22, 2024. There was no documentation that transportation was offered or refused in client record #6.
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Plan of Correction
Director of Clinical Services will provide training to staff regarding following transportation policy and proper documentation to be conducted by 8/30/24. Attestations will be placed in employee HR files. Audits will be conducted weekly by the Clinical Director to ensure 100% compliance. The results will be reported weekly to CEO and leadership team. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure counseling services were provided according to the treatment plan in one of one client records.
Client #1 was admitted on March 18, 2024, and discharged on April 15, 2024. Client #1 ' s treatment plan was completed on March 22, 2024, stating that individual treatment sessions were to occur weekly. There was no individual treatment session documented for the week of April 7-13, 2024.
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Plan of Correction
The Director of Clinical Services will provide training to staff regarding completing weekly individual sessions and documentation by 8/30/24. Attestations will be placed in employee HR files. Audits will be conducted weekly by the Clinical Director to ensure 100% compliance. The results will be reported weekly to the CEO and leadership team.
Training of staff regarding the following treatment plans will be conducted by 8/30/24. Audits to be conducted by the Clinical Director to ensure 100% compliance.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which included a discharge summary, in one of six client records.
Client #6 was admitted on June 18, 2024, and discharged on June 22, 2024. There was a discharge summary documented in client record #6; however, it was not signed and the services provided, client condition at time of discharge, discharge to location and continuing recovery plan sections were blank.
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Plan of Correction
Clinical Services staff will be provided with education on required completion of discharge summaries for detox clients by 8/16/24. Evidence of education will be retained in the HR personnel file. Audits will take place on a weekly basis to ensure documentation is complete for detox clients who have discharged. Weekly audits results will be reported to the CEO and Quality/Risk Manager each Friday with a goal of 100% compliance. |