INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7-9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Alpine Springs Rehabilitation & Recovery Center, LLC 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The facility failed to have a project director that met the qualification for the position.
Thirteen personnel records were reviewed on January 7-9, 2020. One record was reviewed as the project director.
Employee # 1 was hired as the project director on August 5, 2019. The resume was reviewed on January 7, 2020. The employee did not have the required 2 years of experience in a human service agency. The resume did not document any experience in a human service agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A requested change from the Project Director (who did not meet the qualifications) to one who does was sent to DDAP.
The new Project Director will ensure that the Project Director meets all position requirements listed in the regulation currently, and ongoing. |
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
The facility failed to ensure that staff received the mandatory HIV/AIDs and STD/TB training within the first 2 years of employment in eight of eight personnel records.
Thirteen personnel records were reviewed on Janaury 7-9, 2020. Eight required the completion of the mandatory training. Personnel records # 6, 7, 8, 9, 10, 11, 12 and 13 did not document the completion of the HIV/AIDs and STD/TB training.
Employee # 6 was hired as a program technician on October 10, 2017. The mandatory training was due to be completed by October 10, 2019. There was no training documented.
Employee # 7 was hired as a program technician on May 17, 2017. The mandatory training was due to be completed by May 17, 2019. There was no training documented.
Employee # 8 was hired as a program technician on May 23, 2017. The mandatory training was due to be completed by May 23, 2019. There was no training documented.
Employee # 9 was hired as a program technician on October 9, 2017. The mandatory training was due to be completed by October 9, 2019. There was no training documented.
Employee # 10 was hired as a program technician on May 23, 2017. The mandatory training was due to be completed by May 23, 2019. There was no training documented.
Employee # 11 was hired as a program technician on May 14, 2017. The mandatory training was due to be completed by May 14, 2019. There was no training documented.
Employee # 12 was hired as a program technician on August 1, 2017. The mandatory training was due to be completed by August 1, 2019. There was no training documented.
Employee # 13 was hired as a program technician on August 1, 2017. The mandatory training was due to be completed by August 1, 2019. There was no training documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
HR has a list of all Alpine staff who are out of compliance with the HIV / Aids and TB / STD trainings. The HR supervisor will ensure that all staff are trained and in compliance within the required time frame, going forward. Staff that are out of compliance will be trained no later than 1 April 2020. |
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
The facility failed to provide a sufficient number of staff persons certified in CPR, so that at least one person trained in these skills was onsite during the project's hours of operation.
CPR cards and staff schedules were reviewed on Janaury 7-9, 2020. There were no staff certified in CPR onsite on various shifts for four of four weeks reviewed.
Week of December 1-7, 2019. There was no CPR coverage from 6 PM to 8 AM on December 1 and from 6 PM to 8:30 AM on December 2, 2019. There was no CPR coverage from 9 PM to 8:30 AM on December 3 and 6, 2019. There was no CPR coverage from 12 AM to 8:30 AM on December 4 and from 12 AM to 8 AM on December 5 and 7, 2019.
Week of December 8- 14, 2019. There was no CPR coverage from 5 PM to 7 AM on December 11 and 12, 2019. There was no CPR coverage from 9 PM to 7 AM on December 10 and 13, 2019. There was no CPR coverage from 11 PM to 7 AM on December 8, 9 and 14, 2019.
Week of December 15-21, 2019. There was no CPR coverage from 9 PM to 8:30 AM on December 17 and 20, 2019. There was no CPR coverage from 11 PM to 7 AM on December 15, 16 and 21, 2019 and from 11 PM to 8:30 AM on December 18 and 19, 2019.
Week of December 22-28, 2019. There was no CPR coverage from 3 PM to 8:30 AM on December 27, 2019. There was no CPR coverage from 9 PM to 8:30 AM on December 24, 2019. There was no CPR coverage from 11 PM to 7 AM on December 22, 23, 25 and 28, 2019 and from 11 PM to 8:30 AM on December 26, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR supervisor will ensure that staff are scheduled for and trained in CPR. HR Supervisor will review that CPR trained staff are on each shift of the work schedule.
Current staff work schedules were re-arranged so at least 1 person certified in CPR is on each shift. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
The facility failed to have at least 60 square feet of floor space per resident in two of the facility bedrooms.
A physical plant inspection was conducted on January 8, 2020. The lower level room # 3 had two beds and required 120 square feet of space. The square footage of the room was 110 square feet.
Room # 2, also on the lower level had three beds and required 180 square feet of space. The square footage of the room was 176 square feet.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Bunk beds were added and single beds removed to bring the square footage of the rooms into compliance. The Compliance Director oversaw the changes and will keep the rooms in this configuration ongoing. |
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.
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Observations
The facility failed to maintain a written fire drill record that included 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.
Fire drill logs were reviewed from February 2018 to December 2019 were reviewed on January 7-9, 2020.
All fire drills were missing documentation of 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.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citaiton from the January 11, 2018 licensing inspection.
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Plan of Correction
The fire drill record was updated with the suggested changes prior to the DDAP Inspector concluding the January site visit. The Program Technician Supervisor (Linesville facility) and the Compliance Director (Jamestown facility) will use the updated fire drill record during drills and ongoing. |
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
The facility failed to conduct a fire during sleeping hours at least every 6 months.
The fire drill logs from February 2018 to December 2019 were reviewed on January 7-9, 2020. A fire drill during sleeping hours was documented on April 22, 2019. A fire drill during sleeping hours was due to be conducted by October, 2019. There were no overnight fire drill documented from April 2019 to December 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Technician Supervisor conducts fire drills in the Linesville facility. The supervisor will ensure that the 2 drills during sleep hours are conducted as required and ongoing. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to maintain a written fire drill record that included alternate exit routes to be used during the fire drills.
Fire drill logs were reviewed from February 2018 to December 2019 were reviewed on January 7-9, 2020.
All fire drills were missing documentation of the exit routes to be used during the fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"What Exit route was used" was added to the fire drill evaluation record. The Program Technician Supervisor conducts fire drills and will ensure that this item is documented ongoing. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The facility failed to maintain a written fire drill record that included documentation that the facility set off a fire alarm or smoke detector during each fire drill.
Fire drill logs were reviewed from February 2018 to December 2019 were reviewed on January 7-9, 2020.
All fire drills were missing documentation that the facility set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"Did staff set off the alarm in the facility?" was added to the fire drill record. The Program Technician Supervisor conducts the Linesville facility fire drills and will ensure this item is filled out ongoing. |
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
The facility failed to document an annual public report.
Administrative documents were reviewed on January 7-9, 2020. There was no documentation provided that the facility had completed an annual report for the year 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Annual Report will be completed as required; on approx. June 30th of each fiscal year, ongoing. The Project Director will ensure the report is completed. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document an annual written performance evaluation in one of two personnel records.
Five personnel records were reviewed on January 7-9, 2020. Two required an annual evaluation. Employee # 3 did not document an annual evaluation for 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The written performance evaluation will be completed on this employee no later than 2-28-2020. The HR supervisor will ensure annual evaluations are completed on time, ongoing. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent from the client in one of seven client records.
Seven client records were reviewed on Janaury 7-9, 2020. All seven required consent to release information. Client record # 3 did not document a release of information for the funder . There was also a call to a government agency, there was no release documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will be re-trained this week on the proper procedure for completing voluntary client consents. The Clinical Supervisor will review client EMR's for proper consent completion at least weekly and ongoing. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain an informed and voluntary consent from the client which included the specific information to be disclosed in five of eight records reviewed.
Eight client records were reviewed on January 7-9, 2020. All eight were reviewed for consents. Client records # 1, 2, 6, 7 and 8 did not document an informed consent.
Client # 1 documented two releases of information to a funding agency and one release for a government agency which were signed on December 12, 2019. The specific information to be disclosed exceeded the parameters of 255.5.
Client # 2 documented a release of information to a funding agency and one release for a government agency which were signed on December 13, 2019. The specific information to be disclosed exceeded the parameters of 255.5.
Client # 6 documented a release of information to a funding agency and two releases for a government agency which were signed on September 7, 2019. The specific information to be disclosed exceeded the parameters of 255.5.
Client # 7 documented a release of information to a funding agency and one release for a government agency which were signed on October 9, 2019. The specific information to be disclosed exceeded the parameters of 255.5.
Client # 8 documented a release of information to a funding agency and one release for a government agency which were signed on August 23, 2019. The specific information to be disclosed exceeded the parameters of 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will be re-trained this week on client informed and voluntary consents. Specifically, counselors will be trained on the details and requirements of PA 255.5. The Clinical Supervisor will monitor the appropriateness of client consents (in the EMR's) at least weekly and ongoing. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
The facility failed to document a method for the accountability of drugs in two of five client records.
Eight client records were reviewed on January 7-9, 2020. Five clients were prescribed medications. Two clients, # 5 and 8 were missing documentation that the client received their medication as prescribed.
Client # 5 was to receive medication 2x daily. The medication log documented the client received the medication only 1x daily from June 15, 2019 to July 17, 2019.
Client # 8 was to receive medication every twelve hours. Documentation on the medication log showed the client did not recive the medication every twelve hours on September 10, 11 and 12, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nurse Supervisor and Compliance Director contacted the EMR BestNotes company and submitted a request for changes to how medication documentation appears in BestNotes. The Nurse Supervisor will track how medications are documented in the EMR ongoing. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in six of eight client records.
Eight client records were reviewed on Janaury 7-9, 2020. All eight required an individual treatment and rehabilitation plan. Clients # 1, 3, 5, 6, 7 and 8 did not receive counseling services according to the treatment plan.
Client #1 treatment plan was completed on December 24, 2019 and documented client was to receive daily groups. Client did not receive group therapy on December 25, 26, 27, 28, 29, 31, 2019 and January 1, 2, 3, 4, 5 and 6, 2020.
Client #3 treatment plan was completed on December 18, 2019 and documented client was to receive daily groups and weekly individuals. Client did not receive group therapy on December 23, 24, 25, 26, 28, 29, 2019 and January 1, 4, 5 and 6, 2020. Client did not receive weekly individuals for the week of December 22, 2019.
Client # 5 treatment plan was completed on June 28, 2019 and documented client was to receive multiple groups daily and weekly individuals. Client did not receive daily multiple groups on June 29, 30, July 2, 4, 6, 7, 12, 14, 14, 15, 16, 2019. Client did not receive weekly individuals for the week of June 30, 2019.
Client # 6 treatment plan was completed on September 11, 2019 and documented client was to receive multiple groups daily and weekly individuals. Client did not receive daily multiple groups on September 12, 13, 14, 15, 16, 17, 20, 21, 22, 25, 28, 29, 30, October 1, 2, 3, 4, 5 and 6, 2019.
Client # 7 treatment plan was completed on October 15, 2019 and documented client was to receive multiple groups daily and weekly individuals. Client did not receive daily multiple groups on October 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, November 1, 2 and 3, 2019. Client did not receive weekly individuals for the weeks of October 20, 27 and Novemeber 3, 2019.
Client # 8 treatment plan was completed on August 27, 2019 and documented client was to receive daily group and weekly individuals. Client did not receive daily groups on August 28,29,30, 31, September 1, 3, 6, 7 ,8, 11, 14, 15, 16, 17, 18 and 19, 2019. Client did not receive weekly individuals for the weeks of September 15 and 22, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Post inspection, counselors were reminded that they must follow whatever they have stated in the client treatment plan (regarding groups and individual sessions).
The Clinical Supervisor will monitor counselors EMR entries (at least weekly) to ensure that what is stated in the treatment plan is taking place and is documented, ongoing.
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