INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Angel's Light Addiction Specialists 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to document that each counselor met both the education and experiential qualifications for the position.
An offsite inspection was conducted on April 30, 2020 and the qualifications for the position of counselor were reviewed. At the time of the inspection, staff #3 did not meet the experiential qualifications for the position of counselor.
Staff#3 was hired as a counselor on October 22, 2019. Staff #3 hold an Associate's degree in Psychology, which meets the educational requirements; however, at least two years of clinical experience is required. Staff #3 did not have at least two years of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 18 th , Counselor #3 has been moved to a Counselor Assistant Status and will be under close
Supervision by Facility Director until she meets necessary hours needed to meet Full Counselor status.
She also has the option to become fully certified CAADC in the state of Pennsylvania, in which will
qualify her to become a Full Counselor as well.
From 5/18/2020 forward both the Project Director and Facility Director will review all new hires for the position of counselor for the appropriate educational and experiential qualifications. |
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 document at least one person trained in CPR/First Aid was onsite during the project's hours of operation.
An offsite review was conducted on April 30, 2020. Staff schedules and CPR/First Aid cards were reviewed for the period of February 16 - April 11, 2020. A random sample of weeks were reviewed. There was not at least one person trained in CPR/First Aid for 3-11 shifts occurring on February 21, March 6 and April 3, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey from April 30th , 2020, tech schedules were revised to ensure that all shifts currently have trained staff with CPR/First Aid credentials will accompany the staff that are awaiting training. Project Director and Facility Director will secure certified training for CPR/First Aid for all inpatient staff who are not currently trained in these areas. As new hires occur throughout the agency,
additional training's will be scheduled to ensure that all appropriate staff have CPR/First Aid training within the first 90 days. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document fire extinguisher training upon staff employment in staff records #3, #4 and #5.
Staff records were reviewed during an offsite inspection on April 30, 2020. Staff #3, #4 and #5 did not have documentation of fire extinguisher training upon staff employment. Staff #3 was hired on October 22, 2019, Staff #4 was hired on March 13, 2020 and Staff #5 was hired on March 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each personnel file now has a checklist of things that need to be completed upon date of hire or the first day of employment. The Administrative Assistant and the Facility Director will ensure that the fire extinguisher training is done within 7 days of hire. All employees will receive this training via internet video and website. The Administrative Assistant and or Facility Director will ensure that this training becomes part of pre-employment training. They will document it on the employee file checklist and ensure the employee
completes a training evaluation form, indicating that the training was received and on what date. The
Administrative Assistant and the Facility Director will monitor personnel files monthly to ensure that the file is complete and accurate. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills at least once a month.
An offsite review was conducted on April 30, 2020. The fire drill logs for the period of March 2019 - March 2020 were requested. There was no documentation of any fire drill logs for the time period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff responsible for conducting agency fire drills failed to document drills for several months in 2019 and 2020 at Angels Light Addiction Specialists. This issue was addressed by the Program
Director & Facility Director Immediately after they were hired in March 2020. As of May 1st, the Facility Director will monitor monthly fire drills for Angels Light Addiction
Specialists and report any problems directly to the project director. We have had Fire Drills for both April and May and administration has reminders set to discuss the next fire drills in our monthly management meetings. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in staff records #3, #4 and #5.
Staff records were reviewed during an offsite inspection on April 30, 2020. Staff #3, #4 and #5 did not have documentation of emergency training upon staff employment. Staff #3 was hired on October 22, 2019, Staff #4 was hired on March 13, 2020 and Staff #5 was hired on March 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant and Facility Director are responsible for overseeing that all staff have been trained to perform assigned tasks during emergencies. Each personnel file will have a checklist of the training's needed in order to be employed at Angels Light Addiction Specialists. Administrative Assistant and Facility Director will review each personnel file monthly to ensure all training's were completed at the time of hire or soon after the date employed. All staff that have not been trained yet, will be working with another staff member who has had all necessary training's required by DDAP. |
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 which included all required components.
An offsite review was conducted on April 30, 2020. The fire drill logs for the period of March 2019 - March 2020 were requested. There was no documentation of any fire drill logs for the time period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant and Facility Director will ensure that the fire drills are being completed monthly with all fire drill reports and logs to verify times and dates of the random drills. These fire drills will be reviewed monthly by the Administrative Assistant and the Facility Director. This deficiency has been already corrected prior to the inspection on April 30, 2020, shortly after the new Program Director and Facility Director were hired. |
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 drill during sleeping hours at least every 6 months.
An offsite review was conducted on April 30, 2020. The fire drill logs for the period of March 2019 - March 2020 were requested. There was no documentation of any fire drill logs for the time period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 18, 2020, Angel's Light Addiction Specialist Project Director met with the evening Tech Manager to discuss the importance of conducting 11pm-7am unannounced fire drills at least once every six months. The Project Director and the Facility Director are responsible for ensuring this regulation
moving forward. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to document an annual financial audit associated with the project's drug and alcohol abuse services.
An offsite inspection was conducted on April 30, 2020. The annual financial audit for 2018 - 2019 was requested. There was no documentation of an annual financial audit and there was no exception approval.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light requested an exception to the General Standards fro Free-Standing Treatment Activities due to our annual income being less than the required 500,000. This exception was granted on May 18th 2020 via DDAP Division Director.
Tax documentation will be kept on-site for the facility inspection verifying that our income, that it is under 500,000. Should our income increase to an amount over 500,000 we will have the annual financial audit completed. |