INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 3, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Alpine Springs Linesville llc, dba Alpine Springs Rehabilitation and Recovery Center LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the client census, employee schedules, and timesheets, the facility failed to have one FTE primary care staff person available for every seven clients.
On 4/5/23, the client census was 11. There was only one primary care staff on duty from 6am-7am.
On 4/7/23, the client census was 11. There was only one primary care staff on duty from 4:30pm-11pm.
On 4/8/23, the client census was 11. There was only one primary care staff on duty from 12:30pm - 7pm.
On 5/3/23, the client census was 10. There was only one primary care staff on duty from 7:30am - 10am.
This was discussed with facility staff during the investigation.
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Plan of Correction
Supervisors are not scheduled staff and do not clock in and out due to being salaried employees. The clinical supervisor (counselor) and/or nursing supervisor (LPN) were at the facility during the listed times.
Alpine has changed this process and supervisors will clock in/out when onsite and be placed on the schedule when working as professional staff. This will allow us to show we are compliant with the staffing requirements.
Since the visit, these changes have taken place and there have been no times when a professional staff or supervisor is not onsite, on the schedule, and clocked in.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on May 3, 2023, the facility failed to keep the grounds in good repair at all times for the safety and well-being of residents, employees and visitors as evidenced by the following:
Room # 6 had broken armoire doors
Room # 7 had a broken drawer and missing drawer in the armoire
Room # 9 had a broken window blind
The hallway coat closet knob was loose and hanging from the attached screw.
The kitchen has two holes in the drywall on the wall containing the locked refrigerator and freezer.
The administrative office has two chairs with ripped upholstery and missing cove base molding.
This was discussed with staff during the investigation.
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Plan of Correction
Since the visit, the building had a fire on 6/4/23 and it is a complete loss. This was reported as a reportable event on 6/5/23.
The building will meet all building exterior and grounds requirements if rebuilt.
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709.62(a)(3) LICENSURE Completion Requirements
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:
(3) Requirements for completion of treatment.
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Observations
Based on a review of client charts and facility policies, the facility failed to follow their procedures regarding the completion of services in the detoxification activity. The Withdrawal Management Continue Stay Step Down Transfer to 3.5 AM-12 policy indicates that the Medical Director gives a verbal order to release the client from the detoxification activity so the client can step down to the treatment and rehabilitation activity. The doctor ' s order is to be documented in the client chart. Documentation of the doctor ' s verbal order was missing in 3 out of 4 relevant client charts reviewed.
Client # 1 was admitted 4/9/23 and transferred to inpatient rehabilitation services on 4/14/23. There was no documentation of doctor's verbal orders to medically release the client from detoxification services.
Client # 2 was admitted on 4/4/23 and transferred to inpatient rehabilitation services on 4/12/23. There was no documentation of doctor's verbal orders to medically release the client from detoxification services.
Client # 4 admitted 4/11/23 and transferred to inpatient rehabilitation services on 4/16/23. There was no documentation of doctor's verbal orders to medically release the client from detoxification services.
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Plan of Correction
Staff were retained on this policy in the June 2023 staff meeting. Staff document all verbal orders and sends the form to the medical director to sign. Med-23 Determination of Discharge policy was also created and trained to all staff to help assist with meeting this regulation.
For all step downs, staff follows the updated standing order guidelines. When a client meets the criteria, staff fills out the form accordingly. the provider reviews the form, as well as does a visit with the client within 24 hours of intake to in patient to ensure they meet the criteria to step down. This form is signed after the provider visit. the nursing supervisor oversees this and does monthly audits to ensure compliance. The director of operations is responsible for the compliance of this. |
709.63(a) LICENSURE Client record
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:
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Observations
Based on a review of client charts and facility policies, the facility failed to have a complete client record. Facility Hourly Rounds Policy SAF-10 indicates that Program Technicians will monitor the activities and whereabouts of all clients within the facility, conduct hourly rounds/room checks. Program Technician staff are to document each hourly client check. No rounding documentation was observed in five out of five charts reviewed.
Client # 1 was admitted 4/9/23 and transferred to inpatient rehabilitation services on 4/14/23. There was no documentation of hourly checks.
Client # 2 was admitted on 4/4/23 and transferred to inpatient rehabilitation services on 4/12/23. There was no documentation of hourly checks.
Client # 3 was admitted on 4/2/23 and discharged on 4/9/23. There was no documentation of hourly checks.
Client # 4 admitted 4/11/23 and transferred to inpatient rehabilitation services on 4/16/23. There was no documentation of hourly checks.
Client # 5 was admitted on 4/5/23 and discharged on 4/6/23. There was no documentation of hourly checks.
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Plan of Correction
All staff were retrained on this policy in the June staff meeting. We updated the form to make it easier to document, and management audits charts monthly to ensure compliance.
All staff are responsible for documenting the whereabouts of clients according to the policy on each shift. If failed to document, will be held to disciplinary action. Counselors and nurses review the appropriate notes daily and will communicate to their supervisors if they notice any lack of hourly rounds notes. Managers do a monthly audit to ensure compliance. The director of operations will monitor the compliance of this. |
709.64(a)(2) LICENSURE Receiving/storing/preserving food
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a physical plant inspection conducted on May 3, 2023, the facility failed to follow their procedures for storing and preserving food. Per the facility's Dietary policy, all foods will be properly wrapped and marked with the date prepared. Leftovers will be properly stored and may be kept and eaten for three days.
The communal refrigerator was observed to have red liquid spilled all over the food containers and pooled below the lower shelf. In addition, expiration dates were not visible on all of the food items.
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Plan of Correction
Since the visit, the building had a fire on 6/4/23 and it is a complete loss. This was reported as a reportable event on 6/5/23.
Staff was trained on this policy in the June staff meeting. Staff labels all opened food, throws away after 3 days, and checks for expired foods daily. They also check daily to ensure the appliances are kept clean.
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