INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6-8, 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 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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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 personnel records and staff interviews, the facility failed to document a counselor assistant received a written semiannual performance evaluation in one of one applicable records reviewed.
Staff #4 was promoted to counselor assistant on March 1, 2024 and still employed at the time of the inspection. There was no semiannual performance review documented in the staff record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Alpine Springs has a process in place for annual evaluations through our HR system, Bamboo. For all employees, HR is responsible for making sure manager's do annual evaluations by:
-The system automatically sends a reminder when an eval is due to HR and the employee's supervisor.
-The supervisor is to complate the evaluation.
-If the performance of the employee reflects underperformace of the positions standards, they are placed on performance improvement plans to help get the employee up to where they need to b.
-HR monitors the compliance of this.
Alpine Springs will add semiannual evaluations to this process with the same process and monitoring as the annual evaluations for all future employees in the counselor assistant position. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of fourteen records.
Client #12 was admitted on August 13, 2024 and discharged on August 19, 2024. There was a note in the client record indicating disclosures to an individual contact via phone contact on August 17, 2024 but no signed release of information for this individual in the clients record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Alpine Springs has a policy that staff must follow that addresses the process of obtaining consents to release information of a client. All staff will be retrained on this policy in the February staff meeting. All staff will sign off on the policy to ensure understanding. This will be monitored on monthly chart audits by the clinical supervisor and the Director of Operations will be responsible for ensuring compliance. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to document written authentication of verbal medication orders by a physician or other medical professional authorized by State and Federal Law to prescribe medication within the required timeframe, 24-hours for detoxification and 3 business days for inpatient rehabilitation, in six of twelve applicable records.
Client #2 admitted to residential level of care on June 19, 2024 and discharged on July 23, 2024. A verbal order for 8 additional units of insulin was documented on June 20 at 12:48 PM. Written authentication by a physician or authorized medical professional was not documented until June 24.
Client #4 admitted to residential level of care on August 6, 2024 and discharged on September 6, 2024. A verbal order to increase Seroquel to 100 mg PO QHS was documented on August 13 at 5:47 AM. Written authentication by a physician or authorized medical professional was not documented until August 18.
Client #7 admitted to residential level of care on August 30, 2024 and discharged on October 7, 2024. A verbal order for Zoloft 25 mg QD, Remeron 15 mg HS PRN, and discontinue doxepin was documented on August 30 at 2:15 PM. There was no written authentication by a physician or authorized medical professional on this verbal order.
Client #9 admitted to detoxification level of care on August 6, 2024 and stepped down on August 12, 2024. A verbal order to discontinue doxepin 100 mg was documented on August 7 at 4:03 PM. There was no written authentication by a physician or authorized medical professional on this verbal order.
Client #11 admitted to detoxification level of care on October 3, 2024, and discharged on October 14, 2024. A verbal order for Keppra 500 mg PO BID for 14 days was documented on October 4 at 5:29 PM. There was no written authentication by a physician or authorized medical professional on this verbal order.
Client #14 admitted to detoxification level of care on October 18, 2024 and stepped down on October 23, 2024. A verbal order for Valium 5 mg tab PO for four days, two tabs for one day, and then one tab QD for three days, then discontinue was documented on October 19 at 2:03 PM. There was no written authentication by a physician or authorized medical professional on this verbal order.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Alpine Springs has a verbal order form in our EMR. The staff was using paper notes that needed to be signed by the medical director for all verbal orders. This policy and process has changed since the visit. All verbal orders are entered directly into the EMR via the verbal orders note, and the doctor who gave the order must sign the order electrinically in the client's chart. This was addressed with all staff after the visit in January, and will also be addressed to all nurses again in the nursing meeting on 2/3/2025. Staff will sign off understanding of the policy. The nusrsing supervisor will monitor this during monthly audits and the director of operations will be responsible for compliance of this. |
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 one of one applicable detox 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 #11 was admitted to the detoxification level of care on October 3, 2024, and discharged on October 14, 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 retarined on this policy during the January staff meeting, signed off on the policy, and this will be monitored during the monthly audits bythe clinical supervisor. The director of operations will be responsible for complaince 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 three of three 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 #11 admitted on October 3, 2024 and discharged on October 14, 2024.
Client #12 admitted on August 13, 2024 and discharged on August 19, 2024.
Client #13 admitted on September 19, 2024 and discharged on September 24, 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 compiance 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 one 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 #3 was admitted to the residential level of care on July 10, 2024, and discharged on July 27, 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 retarined on this policy during the January staff meeting, signed off on the policy, and this will be monitored during the monthly audits bythe clinical supervisor. The director of operations will be responsible for complaince 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 seven of seven 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 client records reviewed in the residential level of care.
Client #1 admitted on May 7, 2024 and discharged on June 13, 2024.
Client #2 admitted on June 19, 2024 and discharged on July 23, 2024.
Client #3 admitted on July 10, 2024 and discharged on July 27, 2024.
Client #4 admitted on August 6, 2024 and discharged on September 6, 2024.
Client #5 admitted on August 12, 2024 and discharged on September 13, 2024.
Client #6 admitted on August 7, 2024 and discharged on September 19, 2024.
Client #7 admitted on August 30, 2024 and discharged on October 7, 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 compiance 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.
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