INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on a review of administrative records, the facility failed to provide a written policy to address relapse of recovering clinical personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and procedure to address relapse of recovering clinical personnel was written and implemented on July 10, 2023, by the Director fo Operations, Sarah Gorzelsky, and has been added to the facility's Policy and Procedure manual. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of administrative records, the facility failed to provide a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and procedure to address the recruitment and hiring of staff persons who are appropriate to the population to be served was written and implemented on July 10, 2023, by the Director of Operations, Sarah Gorzelsky, and has been added to the facility's Policy and Procedure manual. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of staff records, the facility failed to provide a written semiannual performance evaluation for one of one record.
Staff #5 was promoted to the position of counselor assistant on May 16, 2022. Staff #5 had a documented performance evaluation dated August 1, 2022. Staff #5 ' s next documented performance evaluation was dated June 9, 2023, which is greater than a semiannual basis.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations, Sarah Gorzelsky, is responsible for completing a written semiannual performance evaluation for staff in the position of Assistant Counselor. Semiannual performance evaluations for Assistant Counselors will be completed in June and December of each year. Staff#5 recieved a semiannual performance evaluation on June 9, 2023, and will recieve his next written semiannual performance evaluation on December 9, 2023. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of staff records, the facility failed to provide documentation that a counselor assistant with a high school diploma or GED equivalent counseled clients under direct supervision of a trained counselor or clinical supervisor for the first three months of employment, and under close supervision of a lead counselor or clinical supervisor for the next nine months of employment.
Staff #5 was promoted to counselor assistant on May 16, 2022 and is still in the position at the time of review. Supervision notes were requested from August 2022 to current. No documentation was provided that close supervision occurred during that time frame.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations and Clinical Supervisor, Sarah Gorzelsky, is responsible for providing documented weekly supervision for the first twelve months of employment for Assistant Counselors. Documented supervision notes will be completed by the Director of Operations and CLinical Supervisor, Sarah Gorzelsky, and will be stored in the Assitnat Counselor's personnel file. This weekly documented supervision was implemented on June 14, 2023. |
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 staff records, the facility failed to ensure counselors receive a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training within their first year of employment.
Staff #4 was hired to the position of counselor on January 31, 2022 and was in this position at the time of review. Staff #4 had until January 31, 2023 to complete a four hour TB/STD training and a six hour HIV/AIDS training. Staff #4 completed a four-hour TB/STD training on April 21, 2023 and a six-hour HIV/AIDS training on June 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of July 1, 2023, persons hired as Counselor or Counselor Assistant will recieve a designated training plan with their required first trainings, including a minimum four hour TB/STD training and a minimum six hour HIV/AIDS training. Their training plan will include the end date when their required first year trainings must be completed. The person hired into the mentioned positions will sign and agree to these training terms and recieve their own copy for their records. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on a review of administrative records, the facility failed to provide a written procedure for staff and residents to follow for the evacuation and transfer of residents impaired by alcohol or other drugs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and procedure for staff and residents to follow for the evacuation and transfer of residents impaired by alcohol or other drugs was written and implemented on July 10, 2023, by the Director of Operations, Sarah Gorzelsky, and has been added to the facility's Policy and Procedure manual.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to contact the client's emergency contact when the client left against medical advice (AMA) discharge, as stated in facility policy in one of one client records.
Client #7 was admitted to the inpatient level of care on September 20, 2022 and was discharged against medical advice December 4, 2022. There was no documentation of the emergency contact being notified in client record. #7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 21, 2022 annual licensing renewal inspection.
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Plan of Correction
At 1pm on July 5, 2023, the Director of Operations, Sarah Gorzelsky, trained staff at a mandatory staff meeting on the proper protocol for management/rehabilitation services for clients, including calling the client's emergency contact in the event that the client leaves the facility against medical advice and documenting the effort made to complete this treatment/rehabilitation protocol. A written policy and procedure has been added to the facility policy and procedure manual on July 5, 2023, specifying that the call must be conducted by clinical staff within 24 hours of AMA discharge and it must be documented. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a review of administrative records, the facility failed to provide a written policy and procedures regarding drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and procedure to address drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements was written and implemented on July 10, 2023, by the Director fo Operations, Sarah Gorzelsky, and has been added to the facility's Policy and Procedure manual.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative records, the facility failed to provide a written policy and procedure for the inspection of storage areas that ensures compliance with State and Federal laws and program policy that includes drugs requiring special conditions for storage to ensure stability are properly stored, and copies of drug-related regulations are available in appropriate areas.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and procedure for the inspection of storage areas that ensures compliance with State and Federal laws and program policy that includes drugs requiring special conditions for storage to ensure stability are properly stored, and copies of drug-related regulations are available in appropriate areas was written and implemented on July 10, 2023, by the Director fo Operations, Sarah Gorzelsky, and has been added to the facility's Policy and Procedure manual. This policy includes what is to be verified through the inspection, who inspects, how often, disinfectants and drugs for external use are stored separately from oral and injectable drugs, and drugs requiring special conditions for storage are stored properly, outdated drugs removed, copies of drug-related regualtions are available in appropriate areas.
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709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of administrative records, the facility failed to provide a written client follow-up policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and procedure to address a follow-up policy was written and implemented on July 10, 2023, by the Director fo Operations, Sarah Gorzelsky, and has been added to the facility's Policy and Procedure manual.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of administrative records, the facility failed to provide a written client follow-up policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A policy and procedure to address a follow-up policy for outpatient clients was written and implemented on July 10, 2023, by the Director fo Operations, Sarah Gorzelsky, and has been added to the facility's Policy and Procedure manual. |