INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16-18, 2011 by staff from the Division of Drug and Alcohol 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.
The findings include:
Nine personnel records were reviewed on May 16-18, 2011 Three personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records # 4.
Employee # 4 was hired as a counselor on July 13. 2010. Employee # 4 was hired as a counselor based on the resume which listed a Masters in Community Counseling. There was no verification documented of the employee's degree or major.
An interview with the project/facility director confirmed there was no verification documented of the employee's degree or major.
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Plan of Correction
Employee #4 has requested that the Official transcript be forwarded to Alpha House, Inc. and was informed that this will occur within 3-4 business days (June 15, 2011). This will verify the degree with major. All staff to be hired in the future will be required to produce confirmation of degree and major study for the position prior to the start date. The Executive Director will be responsible for the implementation |
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 a review of personnel records and an interview with the project/facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training in two of two personnel records, as required by regulation.
The findings include:
Nine personnel records were reviewed on May 16-18, 2011. Two personnel records were required to have documentation of TB/STD training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel training records # 8 and 9.
Employee # 8 was hired on July 14, 2008. HIV/AIDS training was due to be completed no later than July 14, 2010 There was no documentation provided that the employee had completed the HIV/AIDS training as of May 18, 2011.
Employee # 9 was hired on March 2, 2009. HIV/AIDS and STD/TB trainings were due to be completed no later than March 2, 2011 There was no documentation provided that the employee had completed the HIV/AIDS or STD/TB trainings as of May 18, 2011.
An interview with the project/facility director confirmed that employee # 8 had not completed the HIV/AIDS training and that employee # 9 had not completed the HIV/AIDS or STD/TB trainings.
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Plan of Correction
Employee #8 will be scheduled to receive the HIV/AIDS training from an Approved BDAP trainer at the next available HIV/AIDS training session (7/14/2011) Alpha House is currently in the process of securing a BDAP approved HIV/AIDS training on site.
Employee #9 will not be scheduled to work until this employee has completed the HIV/AIDS, and STD/TB trainings.
Verifying documentation will be placed in Employee's #8 and #9 training file upon completion of the requirement.
All new hires will be scheduled for HIV/AIDS and STD/TB at the first available BDAP approved training to ensure this deficiency does not recur.
The Residential Director will be responsible for scheduling the trainings. |
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.
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Observations
Based on the review of staff CPR certifications, staff schedules and an interview with the project/facility director, the facility failed to document that at least one person trained in CPR was onsite during the project's hours of operation.
The findings include:
Staff CPR certifications and staff schedules were reviewed on May 16-18, 2011. The facility is a residential program with 24 hour awake staff. The facility failed to document that at least one person trained in CPR was onsite during the project's hours of operation on May 4 and May 11, 2011.
Employee # 5 was the only staff member on shift during the hours from 5:00 PM to 9:00 PM on May 4 and May 11, 2011. There was no documentation that this staff member was currently certified in CPR.
An interview with the project/facility director confirmed that the staff member #5 was not certified in CPR.
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Plan of Correction
Employee #5 completed CPR training 5/19/2011. Documentation is in Employee #5 Training record.
All employees will be required to have CPR training during their probationary employment period (Within 6 months) and prior to being scheduled alone with residents to ensure this deficiency does not recur.
The Residential Director will be responsible for scheduling CPR within this timeframe. |
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 an inspection of the physical plant and an interview with the project/facility director, the facility failed to provide documentation of frozen food being stored at or below 0 degrees Fahrenheit, as required by regulation.
The findings include:
The kitchen was inspected on May 18, 2011 at 2:10 PM and again at 3:30 PM. Per regulation, a residential facility that operates an onsite food preparation area or a central food preparation area shall keep frozen food at or below 0 degrees Fahrenheit. The thermometer in the basement freezer of the 439 address showed the temperature to be 25 degrees Fahrenheit. A temperature log was reviewed which documented freezer temperatures were above the required temperature of 0 degrees Fahrenheit for several weeks.
The project/facility director was present during the physical plant inspection and verified the freezer temperature to be at 25 degrees Fahrenheit. The project/facility director also verified the temperature logs had documented the temperature above 0 degrees Fahrenheit for several weeks.
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Plan of Correction
The food from that freezer was removed and placed in another freezer on premises that registered 0 degrees Fahreneit. Alpha House received another freezer from the Food Bank, 5/27/11, however, the freezer in question is scheduled for repair on or before 6/17/2011. If indicated Alpha House will replace the freezer that didn't register 0 degrees Fahrenheit.
The Residential Director will be responsible for collecting the freezer temperature sheets and any freezer that has a temperature above 0 degrees fahrenheit for 24 hours will have food items removed into another freezer until the temperature reaches 0 degrees and/or formal inspection of the freezer can be obtained. The Residential Director or Residential Counselors in the Residential Directors absence will place their initials beside the date daily to ensure that the sheets have been reviewed for temperature levels and this deficiency does not recur. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of three personnel records, as required by regulation.
The findings include:
Nine personnel records were reviewed on May 16-18, 2011. Three employees were new employees since the last inspection. Per regulation, the residential facility shall instruct all staff in the use of the fire extinguishers upon staff employment. The facility failed to document that fire extinguisher training was completed upon employment in employee records #3 and 5
Employee # 3 was hired on July 13, 2010. Fire extinguisher training was due to be completed no later than July 20, 2010. The facility did not document the completion of fire extinguisher training until May 17, 2011.
Employee # 5 was hired on April 29, 2011. Fire extinguisher training was due to be completed no later than May 6, 2011. The facility did not document the completion of fire extinguisher training until May 17, 2011.
On May 17, 2011, the project/facility director was interviewed and confirmed that fire extinguisher training was not completed upon the employment of employees # 3 and 5.
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Plan of Correction
Alpha House will place on it's employment data sheet beneath the Probationary Appraisal date, the due date of the Fire extinguisher training date for all employee's hired to ensure this deficiency does not recur. The Executive Director will be responsible for ongoing compliance.
Alpha House is scheduling with ABCO Fire Protection Company a fire extinguisher training, June 27, 2011 at 11:00 a.m. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in two of three personnel records, as required by regulation.
The findings include:
Nine personnel records were reviewed on May 16-18, 2011. Three employees were new employees since the last inspection. Per regulation, the facility shall ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. The facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in personnel records #3 and 5.
Employee # 3 was hired on July 13, 2010. The facility did not document the completion of emergency training until May 17, 2011.
Employee # 5 was hired on April 29, 2011. The facility did not document the completion of emergency training until May 17, 2011.
On May 17, 2011, the project/facility director was interviewed and confirmed that completion dates of the emergency training for employees # 3 and 5 were late.
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Plan of Correction
Alpha House will schedule the Emergency Training on the same day that the fire extinguisher training is scheduled. This will be documented in the training file for Employee #3 and Employee #5 as well as all other staff in attendance. ABCO fire protection company confirmed June 27, 2011 at 11:00 a.m.
All new hires will receive Fire Extinguisher and Emergency training within seven (7) days of initial employment (as part of the orientation process)to ensure this deficiency does not recur.
The Executive Director will be responsible for the implementation and ongoing compliance. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records and an interview with the project/facility director, the facility failed to document the results of a reference investigation which included the results of the Pennsylvania State Police Criminal Background check (Act 34) in two of three personnel records.
The findings include:
Nine personnel records were reviewed on May 16-18, 2011. Three personnel records reviewed were new hires and required the Pennsylvania State Police Criminal Background check. There was no documentation of the Pennsylvania State Police Criminal Background check in personnel records # 4 and 5.
Employee # 4 was hired on July 13, 2010. There was no documentation provided that a Pennsylvania State Police Criminal Background check had been completed as of May 18, 2011.
Employee # 5 was hired on April 29, 2011. There was no documentation provided that an application for the Pennsylvania State Police Criminal Background check had been completed, nor was there documentation that a Pennsylvania State Police Criminal Background check had been completed as of May 18, 2011.
An interview with the project/facility director on May 18, 2011 confirmed the Pennsylvania State Police Criminal Background checks had not been completed for employees #4 and 5 and that there was no completion of an application documented in employee record # 5.
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Plan of Correction
Employee #4 and Employee #5 will have Pennsylvania State Police Criminal Background checks. Alpha House is currently reviewing all staff for State Criminal Background check verification and will have documentation in personnel file by 6/17/2011.
All new hires will be required to produce a Pennsylvania State Criminal Background check prior to employment with the agency to ensure this deficiency does not recur.
The Executive Direcetor is responsible for background check implementation and ongoing compliance. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on the review of personnel records and an interview with the project/facility director, the facility failed to document verification of training experience and professional licensure or registration in one of three personnel records.
The findings include:
Nine personnel records were reviewed on May 16-18, 2011. Three personnel records were reviewed for the verification of training experience and professional licensure or registration. There was no verification of professional licensure or registration in personnel record # 4.
Employee # 4 was hired on July 13, 2010. There was no verification documented of the employee's degree or major.
An interview with the project/facility director on May 16, 2011, confirmed the verification of the professional licensure or registration was not provided for employee # 4.
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Plan of Correction
Employee #4 has submitted to the University attended for Official transcript which will verify the degree and major. This will be documented in 3-4 business days from inquiry (6/15/2011).
All new hires must submit official transcript of educational degree and major prior to employment to ensure this deficiency does not recur.
The Executive Director is responsible for this implementation and ongoing compliance. |