INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 9, 2018, by staff from the Division of Drug and Alcohol 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:
|
Plan of Correction
|
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.
|
Observations
The facility failed to ensure that all of its staff received the mandatory training in communicable diseases within the required time frames.
Staff Person #4 was hired as a support staff person on June 20, 2016, and was promoted to a counselor on June 26, 2017. The staff person was required to receive six hour of training in HIV/AIDS by June 20, 2018, but the staff person did not receive the training until September 20, 2018.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Administrative staff and Executive Director will review each employees training schedule semi-annually to ensure that the required trainings are completed within the training year from October 1-September 30. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
The facility failed to document all of the required information in its fire drill records. The facility's fire drill logs from October 5, 2017, through October 2, 2018, were reviewed as part of the presubmission process, and during the on-site inspection.
The documented fire drills for October 5, 2017, November 5, 2017, December 12, 2017, May 18, 2018, and June 6, 2018, did not indicate whether they were conducted during the day or night.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The fire safety information log was revised on 10/9/2018.to include the date and time of the fire drill as well as indicating Am or Pm. The change was reviewed with maintenance person who understood the changes and will review with Executive Director quarterly to ensure compliance. |
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.
|
Observations
The facility did not have a documented annual financial audit for the previous fiscal year at the time of the on-site inspection.
These findings were reviewed with the facility staff as part of the inspection process.
|
Plan of Correction
The annual audit is currently being conducted and is being monitored by the chief financial officer and will be completed by 11/30/2018. The CFO will ensure compliance via annual reviews. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
The facility failed to ensure that it complied with 4 Pa. Code 255.5 in the information that it released to an insurance company.
With the written consent of a patient the facility may only release to insurance companies: (1) Whether the client is or is not in treatment. (2) The prognosis of the client. (3) The nature of the project. (4) A brief description of the progress of the client. (5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
There was an incident report for Client # 2, dated July 17, 2018, sent to the client's insurance company that disclosed that the client sexually and verbally harassed other clients at the facility.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Code 255.5 was reviewed with clinical staff in a staff meeting on October 10th 2018, the legal parameters of information that can be disclosed by the agency for whom the client has signed a consent to not exceed:
1.Presence in treatment.
2.Nature of ACA
3.Brief description of clients progress
4.Client prognosis
5. Whether client has relapsed- and frequency thereof.
This was reviewed with clinical staff in a staff meeting and was understood by the staff. Charts will be reviewed quarterly by the Executive Director to ensure implementation. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to acquire written acknowledgement from clients that the clients were informed of their rights in 7 of 7 records reviewed during the on-site inspection.
There was no documentation that clients were informed of the following rights:
(1) A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Client rights document was revised to include all the rights of a person receiving care under the provisions. All clients will be given the revised document to read, review , sign and date at intake and admission to the facility. They will also be offered a copy of the same. The Executive Director will review charts monthly to ensure the charts are in compliance. |