INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4-5, 2009 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 and a plan of correction is due on July 3, 2009.
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Plan of Correction
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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, the facility failed to provide documentation of TB/STD training in one of one personnel records.
The findings include:
Four personnel records were reviewed on June 4, 2009. One personnel record was required to have documentation of TB/STD training. The facility did not provide documentation of TB/STD training in personnel record # 3.
Employee # 3 is a counselor and was hired April 21, 2008. TB/STD training was due to be completed by April 21, 2009. The facility failed to provide documentation of TB/STD training as of June 5, 2009.
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Plan of Correction
Employee #3 will be scheduled for TB/STD training in August 10 2009 at the St. Paul of the Cross Monastery, 148 Monastery Ave.,Pittsburgh, PA. 15203 This will be evidenced by a certificate of completion placed in Employee #3's training record. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill logs was conducted on June 5, 2009. Documentation of a fire drill conducted during sleeping hours is required once every six months. The only fire drill during sleeping hours was conducted on September 20, 2008. Another fire drill during sleeping hours was due by March 20, 2009.
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Plan of Correction
A fire drill will be conducted by staff during sleeping hours on June 27, 2009, after 10:30 p.m. and before 7:30 a.m.,and during these hours thereafter, once every six months. The Residential Director is responsible for documenting these fire drills and they will be evidenced by recording them in the "Fire Drill Log Book". |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to complete sixty day treatment plan updates in one of two client records.
The findings include:
Four outpatient client records were reviewed on June 5, 2009. Sixty day treatment plan updates were required in two client records. The facility did not document treatment plan updates every sixty days in client record # 4.
Client # 4 was admitted on November 6, 2008 and the comprehensive treatment plan was completed on December 5, 2008. A treatment plan update was due by February 5, 2009. There was no documentation of a treatment plan update as of June 5, 2009.
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Plan of Correction
An attempt will be made to update the 60 day treatment plan for client #4 by the Outpatient Director and/or the client will be discharged due to 3 session absenteeism.
The Outpatient Director will continue to update treatment plans on all outpatient clients every 60 days and this will be evidenced in the client file. The Executive Director will randomly check files for the occurrence of such. |