INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 25 - 26, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alpine Springs Rehabilitation and Recovery Center LLC 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of staff schedules, personnel/training records and an interview with the project/facility director, the facility failed to document first aid training for a sufficient number of staff persons, so that at least one person trained in these skills was available during the project's hours of operation.
The facility provides residential treatment twenty-four hours per day, seven days per week.
No staff with first aid training were onsite during the following dates and times:
December 2 - 3, 2021, December 9 - 10, 2021, December 16 - 17, 2021, December 20 - 24, 2021 and December 27 - 29, 2021 - 5 PM - 11 PM
December 4 - 5, 2021, December 11 - 12, 2021, December 18 - 19, 2021, December 25 - 26, 2021 and December 30 - 31, 2021 - 3 PM - 11 PM
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director met with a designated staff nurse to address the First Aid compliance issue. Staff nurse (with trauma background) developed a First Aid training curriculum (the training points, provided by the Project Director, are based on Red Cross standards).
Since the inspection, Staff nurse has met with and trained all staff (counselors, program technicians, nurses, admissions, drivers) that have direct client care responsibilities.
Staff training was documented and given to HR.
Operations Director will ensure that no less than one First Aid trained staff member is scheduled on every shift.
|
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be disclosed to the funding entity on the consent to release information form in six of seven records.
The consent to release information forms were documented during the intake process and indicated the discharge summary and continuing care plan/transition plan would be release to the funding entity in the following client records:
Client # 1 was admitted January 15, 2022.
Client # 2 was admitted December 28, 2021 and discharged January 19, 2022.
Client # 3 was admitted November 9, 2021 and discharged December 13, 2021.
Client # 4 was admitted November 3, 2021 and discharged December 2, 2021.
Client # 5 was admitted May 28, 2021 and discharged June 26, 2021.
Client # 6 was admitted May 27, 2021 and discharged June 24, 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 8 - 9, 2020 licensing inspection.
|
Plan of Correction
Since the inspection date, the Project Director met with nursing staff, clinical staff, and Admissions staff.
All of the above staff were formally trained on PA 255.5, how to properly fill out the ROI.
Staff Training was documented and given to HR.
The Project Director will monitor documentation / ROI's by nursing, clinical, admissions staff to ensure compliance with PA 255.5 going forward. |
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 written consent to release information form that included the purpose of disclosure in two of seven client records.
The consent to release information forms for a treatment provider were documented during the intake process and indicated the purpose of disclosure was the "release of information".
Client # 4 was admitted November 3, 2021 and discharged December 2, 2021.
Client # 5 was admitted May 28, 2021 and discharged June 26, 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Since the inspection date, the Project Director met with nursing staff, clinical staff, and Admissions staff.
All of the above staff were formally trained on PA 255.5, how to properly fill out the ROI.
This training specifically included inclusion of the "purpose of disclosure" and acceptable purposes for disclosure.
Staff Training was documented and given to HR.
The Project Director will monitor documentation / ROI's by nursing, clinical, admissions staff to ensure compliance with 255.5 / the purpose of disclosure, going forward. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a physical plant inspection, review of medication documentation and facility staff interviews, the facility failed to document quarterly inspections of the medication storage area from January 2021 through December 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 8 - 9, 2020 licensing inspection.
|
Plan of Correction
Project Director updated the MED-15 Policy to include the specific items required on this POC item. Also developed a form to track said items (quarterly). This form was given to the lead nurse to complete the quarterly inspection (at each facility) by the first week of Feb. 2022. Staff nurse completed the medication inspections on Feb. 4 (Jamestown facility) and Feb. 7 (Linesville facility), 2022. The lead nurse will be responsible for monitoring that all quarterly medication inspections are completed and documented on the approved form. |