INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9-10, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alpine Springs Linesville LLC, DBA 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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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of the administrative information, the facility failed to document a policy and procedure for security of drugs, including, but not limited to, the loss, theft, or misuse of drugs.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
This policy was revised on 1/8/2025 to include the security of drugs, including, but not limited to the loss, theft, or misuse of drugs. All staff signed off on the policy in January. Nursing supervisor is responisble for the implementation of the changes ot the policy and compliance. Compliance of this will be monitored monthly by the nursing supervisor on monthly inspection and the director of operations will ensure compliance to prevent reocurance of deficiency. |
709.62(a)(4) LICENSURE Criteria - Discharge/termination
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against medical advice in two of two applicable detox client records.
The facility's policy and procedure manual states the client ' s emergency contact will be notified immediately but no later than 12 hours following a client ' s decision to leave the facility against medical advice.
Client #2 was admitted to the detoxification level of care on November 7, 2024, and discharged on November 11, 2024. There was a consent for the emergency contact in the record.
Client #3 was admitted to the detoxification level of care on November 7, 2024, and discharged on November 11, 2024. There was a consent for the emergency contact in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Alpine's policy and procedure manual states that the client's emergency contact will be notified immediately but no later than 12 hours following a client's decision to leave the facility against medical advice. Staff were retrained on this policy during the January staff meeting, signed off on the policy, and this will be monitored during the monthly audits by the clinical supervisor. The director of operations will be responsible for compliance of this plan of correction and policy. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in four of four applicable detox client records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 7 days and again at 6 months.
There was no follow up information documented in any applicable client records reviewed in the detoxification level of care.
Client #1 admitted on November 4, 2024 and discharged on November 8, 2024.
Client #2 admitted on November 7, 2024 and discharged on November 11, 2024.
Client #3 admitted on November 7, 2024 and discharged on November 11, 2024.
Client #4 admitted on October 31, 2024 and discharged on November 10, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Alpine Springs has revised our policy and process for compliance of this standard. Our EMR system will automatically send out emails or texts with follow-up contact for all clients within 7 days, 6 months, and 1 year of all discharges. All staff were retrained on this revise policy during the January staff meeting. The director of operations will monitor the compliance of this. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against medical advice in two of two applicable residential client records.
The facility's policy and procedure manual states that the client ' s emergency contact will be notified immediately but no later than 12 hours following a client ' s decision to leave the facility against medical advice.
Client #10 was admitted to the residential level of care on December 24, 2024, and discharged on December 31, 2024. There was a consent for the emergency contact in the record.
Client #11 was admitted to the residential level of care on October 28, 2024, and discharged on November 3, 2024. There was a consent for the emergency contact in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Alpine's policy and procedure manual states that the client's emergency contact will be notified immediately but no later than 12 hours following a client's decision to leave the facility against medical advice. Staff were retrained on this policy during the January staff meeting, signed off on the policy, and this will be monitored during the monthly audits by the clinical supervisor. The director of operations will be responsible for compliance of this plan of correction and policy. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of three discharged residential client records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 7 days and again at 6 months.
There was no follow up information documented in any applicable client records reviewed in the residential level of care.
Client #8 admitted on November 12, 2024 and discharged on December 3, 2024.
Client #10 admitted on December 24, 2024 and discharged on December 31, 2024.
Client #11 admitted on October 28, 2024 and discharged on November 3, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Alpine Springs has revised our policy and process for compliance of this standard. Our EMR system will automatically send out emails or texts with follow-up contact for all clients within 7 days, 6 months, and 1 year of all discharges. All staff were retrained on this revise policy during the January staff meeting. The director of operations will monitor the compliance of this |