INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alpha House 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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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 review of the physical plant, the facility failed to ensure that frozen foods were kept at or below 0 degrees Fahrenheit.
The freezer located in the facility ' s basement had a thermometer that read 20 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will conduct a weekly review of fridge and freezer temperatures to monitor that all fridges and freezers are of proper temperature according to health department standards. Freezers will be recorded at 0 degrees farenheit and if any fridge or freezer is found to not be at proper temperature will be removed for repair or replacement, and food will be thrown out.
The freezer located during the inspection that temped at 20 degrees was removed for repair and food was thrown out on June 11, 2025 after the inspection.
Plan of action is implemented on 06/18/2025. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in four of seven applicable records.
Client #3 was admitted to the inpatient level of care on March 19, 2025 and was active at the time of review. Client #3's record contained a treatment plan update dated April 19, 2025. The next treatment plan update was due no later than May 19, 2025; however, the next treatment plan update was not completed until May 20, 2025.
Client #4 was admitted to the inpatient level of care on December 13, 2024 and was discharged May 6, 2025. Client #4 ' s record contained a treatment plan update dated March 6, 2025. The next treatment plan update was due no later than April 6, 2025; however, the next treatment plan update was not completed until April 18, 2025.
Client #5 was admitted to the inpatient level of care on December 9, 2024 and was discharged March 15, 2025. Client #5's record contained a treatment plan update dated February 7, 2025. The next treatment plan update was due no later than March 9, 2025; however, the next treatment plan update was not completed until March 12, 2025.
Client #6 was admitted to the inpatient level of care on November 20, 2024 and was discharged February 18, 2025. Client #6 ' s record contained a treatment plan update dated December 18, 2024. The next treatment plan update was due no later than January18, 2025; however, the next treatment plan update was not completed until January 27, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will conduct monthly chart reviews of client treatment plan completion dates to ensure that each client's treatment plan is reviewed and/or updated at least every thirty days.
Director of Operations discussed this requirement with the counselors during their clinical staff meeting on Wednesday, June 18, 2025 to ensure understanding and compliance.
Plan of correction goes into effect June 18, 2025. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure there was a complete client record, which includes case consultations notes, in three of seven applicable records.
Facility policy and procedure states that a case consultation is to be completed once for every month the client is in treatment.
Client #1 was admitted to the inpatient level of care on April 29, 2025 and was active at the time of review. No case consultation note was found in Client #1 ' s record for May 2025.
Client #2 was admitted to the inpatient level of care on April 9, 2025 and was active at the time of review. No case consultation note was found in Client #2 ' s record for May 2025.
Client #7 was admitted to the inpatient level of care on November 6, 2024 and was discharged March 18, 2025. No case consultation note was found in Client #7 ' s record for January 2025 or February 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will conduct chart reviews for case conference notes monthly to ensure that counselors are discussing and completing case consultations in staff meeting with the clinical team for each of their clients at least once a month.
The first chart review for case conference notes was conducted on 06/18/2025.
Plan of correction is in effect, as of June 18, 2025. |