INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2022 through October 6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alternative Counseling Associates, Inc. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and the supervisor, documented in one of six applicable personnel records reviewed.
Employee #1 was hired as the project director/facility director on December 15, 2021. The individual training plan was signed and dated by the employee on December 7, 2021; however, the training plan was not signed by the supervisor and there was no additional documentation indicating the plan was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director, reports to the Board Chair, who resides in Florida. The Board Chair has been notified that the training plan needs to be completed and signed.
The Board Chair will be available again during the weeks after a full Board Meeting and the signed plan will be obtained by the Facility Director.
The Board Chair was contacted and spoke with the Executive Director. Together they reviewed the Individual Training Plan. The Board Chair has forwarded the signed copy of the required training plan via email.
The Board Chair has been made aware of the the month in which ACA has it's yearly DDAP site visit. The Executive Director of ACA will sent monthly email reminding the Board Chair of this important date.
In addition, the need for an updated training plan and Board Chair signature will be placed on their agenda each month for the meeting between Program's Executive Director and Board Chair.
Therefore, the Training Plan and signature can be reviewed and completed at the earliest opportunity.
The above corrective action has been received and completed on the above listed corrective action date. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframe in one of seven applicable personnel records reviewed.
Employee #7, an administrative coordinator hired on May 13, 2019, was due to receive a minimum of six hours of HIV/AIDS training and at least four hours of TB/STD training no later than May 13, 2021; however, there was no documentation that either the HIV/AIDS or TB/STD trainings were completed as of the date of the inspection.
This is a repeat citation from the October 1, 2021 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
No DDAP approved trainings were available due to Covied-10 during the period being assessed. Recently with the availability of approved online programming, the references staff have already begun and will comlplete all the required trainings.
Employee #7, the Administrative Program Coordinator, in keeping with the above mentioned approved training, will also complete those relevant and required by her.
The Executive Director has met with the Administrative Program Coordinator, to monitor and review the progress of completing the required trainings.
Employee #7 has already completed a confidentiality training is currently signed-up for the approved up-coming HIV training and will continue to seek out the needed approved courses and required hours as they become available.
Employee #7 has identified the needed trainings. These training will be completed during the months of April, May, and June of 2023.
The Executive Director will ongoingly meet with this employee on a monthly basis, to further monitor, and assure that the required hours of trainings are met, and will continue accordingly to do so.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's July 1, 2021 through June 30, 2022 training year in two of two applicable personnel records reviewed.
Employee #2's personnel record documented 23 hours of annual training for the reviewed training year.
Employee #3's personnel record documented 22 hours of annual training for the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The date of the ACA Policy related to when all counselor trainings must be completed, was changed to July, under the prior administration. This date no longer coincided with our DDAP site review date and posed problems in obtaining all the required credits in a shorter time-frame. All the needed hours have now been fulfilled.
Subsequent to our recent Site Visit the Policy has been changed back to coordinate this requirement to be completed by the October, the month of our site visit, rather than July.
The Executive Director is responsible for seeing that those individual counselors requiring credit hours for certification and/or licensure have them completed by the DDAP Site Review date.
As noted previously the prior Executive Director changed the time-frame for the required training hours to be completed,(July), rather than what it had always been prior. This sooner date, did not afford Counselors,#1 & #2 the full compliment they were accustomed-to, and needed, to fulfill the required hours.
As also noted in the previous response submission, the current Executive Director has changed the Policy back to a completion date of October 1st, affording the Counselors more time to complete the credit hours.
To further assure that Counselors at ACA are on task to obtain the needed training hours, they will be required to submit certificates or other valid proof of hours obtained to the Executive Director on a quarterly basis. They will also be asked to make known any obstacles they may face toward reaching their hourly goal. The Administrative Program Manager will assist in this monitoring process with the Counselors.
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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 conducted on October 6, 2022, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The 3rd floor bathroom, located in building #440, had a combination shower/tub with what appeared to be mold and mildew on the floor of the tub, as well as on the shower walls and soap holder.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 3rd floor bathroom, located within 440 E. Hight St, which had mold and or mildew on the floor, or of the tub, as well as on the shower, walls, and soap dish, was immediately cleaned and disinfected by the end of the business day, of our recent
DDAP site visit by ACA Maintenance.
The Lead Monitor/Tech, will review the weekly reports of the other Monitors doing nightly rounds. The Lead will also check personally at the end of each week for anything requiring further attention.
Should additional disinfecting/cleaning be required, residents and follow-up by maintenance will be engaged to assure thorough cleaning is completed,
The Lead Monitor reports to The Administrative Program Director. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that cold food was kept at or below 40 degrees Fahrenheit. The refrigerator, located in the 3rd floor kitchen of building #438, registered a temperature of 50 degrees Fahrenheit at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The thermometer in the refrigerator located on the 3rd floor kitchen of the building at 438 E. High St. was replaced.
Subsequently, the temperature of the refrigerator is displayed as being within the 40 degree Fahrenheit range.
The Lead Monitor who reports to the Administrative Program Coordinator is
primarily responsible for implementing this level of activity.
A memo to all Monitoring Staff has been drafted to have the evening Monitors ask the client-residents at the 9:45 PM meeting, to check the refrigerator thermometers and report if temperatures are higher than 40 degrees Fahrenheit.
In keeping with this, the Lead Monitor will have the refrigerators temperatures checked by Monitoring Staff weekly.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the October 2021 through September 2022 fire drill logs, the facility failed to conduct an unannounced fire drill, at least once a month.
There was no documentation of fire drills being conducted during the months of October 2021, February 2022, and August 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Conducting of monthly fire drills has been placed under the individual newly hired for ACA Manintenance, reporting to the Facility Director. This individual will conduct the required drills and report them monthly to the Facility Director.
As noted previously, the ACA Maintenance person, will assume the responsibility for this function. To further assure that this is continuously performed, for this task, the scheduling and performance of drills will be coordinated in conjunction with the Administrative Program Monitor,(APM). The APM will place these on the Executive Director's monthly calendar, so that they may be monitored for compliance at that level.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility, which is publicly funded, failed to complete and make available to the public an annual report, which is to include a statement disclosing the names of officers, directors, and principal shareholders.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The necessity for the Annual Report was sent to the Board Chair in order that steps be taken to fulfill this requirement.
The ACA Executive Director met in-person with the Board Chair, who is responsible for facilitating Corporate financial requests and documentation. Subsequent to that meeting, an independent certified accountant, was in-touch with the ACA Executive Director to inform him that he was enlisted to produce the required document.This information will be made available on March,30,2023
Going forward the need for this requirement will be communicated to the Board Chair, both via email and in-person, several months prior to the yearly DDAP visit, and that this information is to be furnished each year, in order to be in compliance. |
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 an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures for the current year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director, updated and consolidated the 2 transitioning Policy Books into one, and has presently signed that written manual.
A single Facility Policy and Procedures Manual was compiled by the current Executive Director, which included updated and new polices.
Subsequent to our Licensing visit, a current sign-off sheet was placed within the first tab of the Policy Book, with the current Executive Director's signature and dated. |
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 the policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client record reviewed.
Per the facility ' s policy and procedure manual, the program will contact the participant's emergency contact when the participant leaves treatment against facility advice.
Client #5 was admitted on March 21, 2022 and was discharged against facility advice on April 15, 2022. There was no attempted emergency contact notification documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In the event a client leaves against facility advice, it will ce the responsibility of the Tratment Monitors to initiate communication with the the emergency contact for that clinet. This will be followed-up by the counselor to insure this has taken place. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The necessity for this requirement to be met has been forwarded the the Board Chair of ACA.
The process as stated for actions required by the Governing Body, are also applicable for the fulfillment of this fiscal requirement, as follows:
The ACA Executive Director met in-person with the Board Chair, who is responsible for facilitating Corporate financial requests and documentation. Subsequent to that meeting, an independent certified accountant, was in-touch with the ACA Executive Director to inform him that he was enlisted to produce the required document(s).This information will be made available by March,30,2023
Going forward the need for this requirement will be communicated to the Board Chair, both via email and in-person, several months prior to the yearly DDAP visit, and that this information is to be furnished each year, in order to be in compliance. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client in one of seven client records reviewed.
Client #1 was admitted on August 25, 2022 and was active at the time of inspection. There was a release of information form to a human service agency signed and dated by the client on August 25, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
This is a repeat citation from the October 1, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To further ensure and underscore the need for the Confidentiality Agreement to both offered and circled in the clients charts as having been done, a memo addressing this subject has been sent to all ACA Counseling staff.
This topic will also be addressed in their next individual supervision session with the current Executive Director.
Incoming client/residents meet initially with the Administrative Program Manage, and subsequently with the Lead Monitor. These staff have been met with to go over the need for the Confidentiality Agreement and chart notation be made by circling that client has been offered a copy of the agreement.
Furthermore, ACA Counseling Staff have also been met with to follow-up on the memo which was sent regarding this matter.
Subsequently, during each counselors meeting with the Executive Director for case review and supervision, the matter of the Confidentiality Agreement being offered to each client and noted accordingly in the chart, will be reviewed to assure completion.
The Executive Director will ultimately be responsible for the completion of this requirement.
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