INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2007 through September 20, 2007 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on October 15, 2007.
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Plan of Correction
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709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a complete medical history on the client in five of five client records reviewed, #1, 2, 3, 4 and 5. There was no history of illnesses for the client. The medical histories collected on the clients consisted only of a list of symptoms, and a list of illnesses for family members.
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Plan of Correction
1. Alpha House believed it was in compliance.
2. Compliance was achieved 9-20-2007.
3. Alpha House devised a "Health History" sheet that list illnesses and a response for "self" as well as family members. The Supervising Counselor is responsible for ongoing compliance |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client charts, the facility failed to document aftercare plans with goals and time frames in two of two client records reviewed, #4 and 5. Time frames were missing.
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Plan of Correction
1. This was an oversight of the Residential Counselor and Supervising Counselor responsible for oversight of the client's #4 and 5.
2. Alpha House will be compliant from 10-18-2007 at the staff meeting as evidenced in minutes and ongoing. A sample aftercare plan will be issued with correct procedures outlined.
3. All aftercare plans will have goals and time frames. This will be monitored by the Supervising Counselor and randomly checked for continuing compliance by the Residential Director.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a complete medical history on the client in four of four client records reviewed, #1, 2, 3 and 4. There was no history of illnesses for the client. The medical histories collected on the clients consisted only of a list of symptoms, and a list of illnesses for family members.
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Plan of Correction
1. Alpha House believed it was in compliance.
2. Compliance was achieved9-20-2007.
3. Alpha House devised a "Health History" sheet that list illnesses and a response for "self" as well as family members. The Supervisiong Counselor is responsible for ongoing compliance. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document a complete medication record in one of one client record reviewed, #3. The client's medications were listed, but the prescribed dosage and frequency were missing.
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Plan of Correction
1. This was an oversight on the Residential Counselor responsible for this client #3.
2. Alpha House became compliant 9-20-2007.
3. The dosage and frequency were added to the medication sheet of client #3. The Supervising Counselor is responsible for ongoing compliance of the medication sheets. The Residential Counselor will review the medication sheets for their assigned clients every month for accuracy of documentation and sign on the back of the sheet that these have been inspected for accuracy. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans with goals and time frames in three of three client records reviewed, #4, 5 and 6. Time frames were missing.
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Plan of Correction
1. This was an oversight of the Residential Counselor and the Supervising Counselor responsible for oversight of the client's #4,5, & 6.
2. Alpah House will be compliant from 10-18-2007 at the staff meeting as evidenced in minutes and ongoing. A sample aftercare plan will be issued with the correct procedures outlined.
3. All aftercare plans will have goals and time frames. This will be monitored by the Supervising Counselor and randomly checked for continuing compliance by the Residential Director. |
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
Based on a review of employee records, program schedules and interviews with staff, the facility failed to ensure that at least one person certified in CPR was onsite 24 hours a day. One employee without current CPR certification was the sole employee on the schedule from 9:00 PM to 9:00 AM on 8/21/07, 8/23/07, 8/28/07, 8/30/07, 9/4/07, 9/6/07, 9/11/07, 9/13/07, and 9/18/07.
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Plan of Correction
1. Alpha House believed it was in compliance.
2. Alpha House became compliant the next day, 9-21-2007. This employee had been previously scheduled to attend the next day.
3. The Executive Director will have all employees receive CPR certification or they will not be permitted to work without current certification. When Alpha House schedules CPR training, any employee unavailable to attend will have 30 days thereafter to come into compliance and prior to their current CPR expiration date. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of employee records and staff interviews, the facility failed to ensure that one counselor received the required 25 hours of training annually. Employee #6 only received 21.25 training hours for the program's 7/1/06-6/30/07 annual training year.
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Plan of Correction
1. Alpha House believed it was compliant with employee training hours. The employee took additional hours of training, however they will be applied to the next training review.
2. Alpha House will be compliant with required training hours of employee's for the next annual training year.
3. The Executive Director will require all employees to be responsible for achieving their individually required training hours. The Executive Director will check the training files of all employee's every six months and inform staff of the number of training hours still needed for the annual training year. |