INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10-12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Alpha House 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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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 document that fire drills were conducted during sleeping hours at least every six months.
Fire drill logs were reviewed for the time period of August 2018 to May 2019. A fire drill was conducted during sleeping hours on August 25, 2018. A fire drill during sleeping hours was next due to be completed in February, 2019. There were no fire drills during sleeping hours documented after August 25, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Night Monitor will conduct a fire drill after during sleeping hours, after 11:15 pm and before 7:30 am, no less than once every 6 months. These fire drills will occur ongoing as specified in the regulation. The Residential Director will be responsible for scheduling and coordination with Night Monitor staff, and general oversight of the completion of the fire drills during sleeping hours, and to ensure proper the completion of the report. This report will be documented and filed with the Executive Director in the "Fire Drill Log Book". |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to develop a written procedure which complied with 4 Pa Code 255.5.
The policy and procedures manual was reviewed on June 10-12, 2019. Policies and procedures, regarding unusual incidents and grievances, documented what information is to be provided to a funding source. The information that is to be provided, per policy, exceeds what is allowed by 4 Pa Code 255.5.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Alpha House believed it was in compliance with the written policy and procedure regarding Confidentiality as it relates to unusual incidents and grievances. Upon learning that the written procedure did not comply with 4 Pa Code 255.5, the Executive Director began the process of updating the written policy and procedure to reinforce that which is allowed by 4 PA Code 255.5.
Under the direction of the Executive Director, the procedure is being updated to clarify policies surrounding unusual incidents and grievances to reflect that which is allowed by 4 Pa Code 255.5. Additionally, it is being clarified to reflect that all record requests shall first go to a client's designated Residential Counselor, and then if their Residential Counselor has questions about their validity, they will then go to the Residential Director. If requests are determined to be invalid, the Residential Counselor or Residential Director will deny the request for information, and all information as such will be documented in the client's file.
Under the direction of the Executive Director, The procedure is being further updated to clarify who has access to client records, client information, and for what purpose. These changes to written procedure will reinforce Confidentiality, and the specific limitations within 4 Pa Code 255.5, for insurance carriers and/or other funding sources (e.g., 5-point letter).
Additionally, the Executive Director is updating language within the written policy and procedure. One example includes replacing "HIPPA Coordinator" with "Residential Director." The previous description it improperly suggested that Alpha House was following HIPAA guidelines rather than the stricter policies laid out in 4 PA Code 255.5.
Under the direction of the Executive Director, the procedure is being updated to clarify that the Residential Counselors are responsible for maintaining Confidentiality to that which is allowed by 4 Pa Code 255.5, especially surrounding unusual incidents, grievances, and in correspondence with funding sources.
The Executive Director is responsible for finalizing the written policy and procedures on or before 08/31/2019, distribution of the revised written procedure, and initial implementation. The Residential Director is responsible for the supervision of the implementation, supervision of the Residential Counselors, maintenance of confidentiality, and maintenance of client records.
The Executive Director has notified Alpha House staff of the necessary changes to the written policy, as reflected in the staff meeting minutes on 06/27/2019 and 7/11/2019.
Going forward, under the direction of the Executive Director, the Residential Director will ensure all unusual incidents, grievances, and consents continue to follow and reflect that which is allowed by 4 Pa Code 255.5.
Residential Counselors will attach consents to disclosure of client information and maintained in the client record.
The Residential Director will monitor the release of client information at a minimum of a monthly basis, as evidenced by the chart review sheet.
Under the direction of the Executive Director, Alpha House will have the written procedure finalized on or before 08/31/2019.
The Executive Director will provide Alpha House staff with copies of the updated written procedure, as evidenced by future meeting minutes.
The Executive Director and Board of Directors will continue to review the Policy and Procedure book at a minimum of an annual basis, as evidenced by the signature sheet. |
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
The facility failed to obtain a consent from the client in one of twelve client records reviewed.
Twelve client records were reviewed for consents on June 10-12, 2019.
Client record # 1 documented a letter dated, May 30, 2019, that had been faxed to a company. There was no documentation of a consent to release the information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This specific incident, in which there was no documentation of a consent to release information for Client #1, was an unusual and rare oversight by Alpha House counseling staff and a failure to follow existing procedures. The Residential Counselors and Residential Director are responsible for charting and consent forms. This incident was reviewed with Clinical staff, as evidenced by the 06/27/2019 and 07/11/2019 meeting minutes.
While Alpha House's policy and procedure were not found to be deficient, under the direction of the Executive Director, Alpha House has begun the process of updating the written policy and procedure to further emphasize that which is allowed by 4 PA Code 255.5. These updates expand upon what constitutes informed and voluntary consent, helping the client fully understand what they are consenting to.
Per 4 Pa Code 255.5, the Residential Counselors and Residential Director of Alpha House shall not disclose or be used to disclose client data which reasonably may be utilized to identify the client to any person, agency, institution, governmental unit, or law enforcement personnel without the written, informed consent of the client.
The Residential Counselors will obtain all consents in writing, and all consents will include specific information to be disclosed and the purpose of the disclosure, be filled out completely (with dated signatures from both the client and a witness), and monitored by the Residential Director.
Should changes to consents be necessary, or additional consents needed beyond those in the intake packet, they will be obtained by the Residential Counselors, retained in the client chart, and monitored by the Residential Director.
Charts will be reviewed randomly by the Residential Director, at a minimum of a monthly basis, to ensure continued compliance, as evidenced by the chart review sign-off sheet.
If the Residential Director should find an error, they will be immediately reviewed with the Residential Counselor who garnered them. Under the guidance of the Residential Director, the Residential Counselor will then obtain a new consent from the client.
The Residential Director will continue to monitor and reinforce the importance of properly completed written consents through regular clinical supervision, and as needed at all-staff-meetings. The Residential Director shall promptly notify the Executive Director of any issues going forward to ensure there is not a recurrence. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain a consent from the client which included the specific information to be released in five of twelve client records reviewed.
Twelve client records were reviewed for consents on June 10-12, 2019. Client records # 5, 7, 10, 11 and 12 did not document the specific information to be released.
Client # 5 documented a release, with no signature dates, that was missing the specific information to be released.
Client # 7, documented a release, signed on February 15, 2019, that was missing the specific information to be released.
Client # 10, documented a release, signed on February 23, 2019, that was missing the specific information to be released.
Client #11, documented a release, signed on December 16, 2018, that was missing the specific information to be released.
Client #12 documented a release, signed on December 13, 2018, that was blank for the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was an oversight of the Residential Counselors and Residential Director, responsible for oversight of the client #5 and #7, #10, #11, and #12's charting and consent forms.
The Executive Director and Residential Director reviewed these errors with staff, as evidenced by the 06/27/2019 and 07/11/2019 meeting minutes.
Going forward, all consents received will evidence the specific information to be disclosed. All signatures will be properly dated.
All client consents will be regularly reviewed by the Residential Counselors. Charts will be reviewed randomly by the Residential Director, at a minimum of a monthly basis, to ensure continued compliance and that the specific information to be disclosed has been identified.
If found, any improperly documented consents will be reviewed by the Residential Director with the staff member who garnered them. They will then obtain a new consent from the client.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to obtain a consent from the client which included the purpose of disclosure in five of twelve client records reviewed.
Twelve client records were reviewed for consents on June 10-12, 2019. Client records # 5, 7, 10, 11 and 12 did not document the purpose of disclosure.
Client # 5, documented a release, with no signature date, that was missing the purpose of disclosure.
Client # 7, documented a release, signed on February 15, 2019, that was missing the purpose of disclosure.
Client # 10, documented two releases, signed on February 23, 2019, that were missing the purpose of disclosure.
Client #11, documented a release, signed on December 16, 2018, that was missing the purpose of disclosure.
Client #12 documented a release, signed on December 13, 2018, that was missing the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was an oversight of the Residential Counselors and Residential Director, responsible for oversight of the client's #5 and #7, #10, #11, and #12.
The Executive Director notified Alpha House staff as evidenced by the 06/27/2019 meeting minutes.
Going forward, all consent forms will reflect the purpose of the disclosure. All signatures will be properly dated.
All client consents will be regularly reviewed by the Residential Counselors. Random chart reviews will be completed by the Residential Director, at a minimum of a monthly basis, to ensure continued compliance and ensure the purpose of the disclosure has been identified.
If found, any improperly documented consents will be reviewed by the Residential Director with the staff member who garnered them. They will then obtain a new consent from the client. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to document that the client was provided written acknowledgement of their rights which included: that reasons for removing sections shall be documented in the record, in twelve of twelve client records.
The client handbook, and twelve client records were reviewed on June 10-12, 2019. Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 documented that the client had been provided the handbook. The handbook included the client rights. The handbook was missing documentation that the: reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Alpha House believed the Client Handbook was in compliance. Upon learning that the client handbook did not comply with 28 Pa Code 709.30, the Executive Director began amending the handbook to include the full language of client rights within 28 Pa Code 709.30.
The Executive Director notified Alpha House staff of the necessary changes to the Resident Rights section of the Client Handbook, as evidenced in the 06/27/2019 and 07/11/2019 meeting minutes.
The Executive Director has revised the Residents Rights section of the Client Handbook to reflect, "Reasons for removing sections shall be documented in the record."
The Executive Director informed all residents retained in care of the change to the handbook, and reminded them of their specific rights. The Executive Director distributed revised copies of the handbooks on 07/12/2019. On that date, The Executive Director allowed for questions to be asked, garnered signed acknowledgement of the changes, and confirmation of reception of the revised handbook. All signature pages have been charted by the Residential Counselors, under the direction of the Residential Director.
Going forward, Residential Counselors will copy and distribute the revised handbook to all clients at intake, and receive signed acknowledgement of that reception. The Residential Director will be responsible for ensuring all old copies of the handbook have been removed and the revised copy is being distributed.
The Executive Director has updated the Policies and Procedures book to include the revised copy of the Client Handbook, which will be maintained going forward. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to document that the client was provided written acknowledgement of their rights which included that: the client had the right to appeal a decision limiting access to their records to the director, in twelve of twelve client records.
The client handbook, and twelve client records were reviewed on June 10-12, 2019. Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 documented that the client had been provided the handbook. The handbook included the client rights. The handbook was missing documentation that: the client had the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Alpha House believed the Client Handbook was in compliance. Upon learning that the client handbook did not comply with 28 Pa Code 709.30, the Executive Director began amending the handbook to include the full language of client rights within 28 Pa Code 709.30.
The Executive Director notified Alpha House staff of the necessary changes to the Resident Rights section of the Client Handbook, as evidenced in the 06/27/2019 and 07/11/2019 meeting minutes.
The Executive Director has revised the Residents Rights section of the Client Handbook to reflect, "Residents have a right to appeal a decision limiting access to their records to the Director."
The Executive Director informed all residents retained in care of the change to the handbook, and reminded them of their specific rights. The Executive Director distributed revised copies of the handbooks on 07/12/2019. On that date, The Executive Director allowed for questions to be asked, garnered signed acknowledgement of the changes, and confirmation of reception of the revised handbook. All signature pages have been charted by the Residential Counselors, under the direction of the Residential Director.
Going forward, Residential Counselors will copy and distribute the revised handbook to all clients at intake, and receive signed acknowledgement of that reception. The Residential Director will be responsible for ensuring all old copies of the handbook have been removed and the revised copy is being distributed.
The Executive Director has updated the Policies and Procedures book to include the revised copy of the Client Handbook, which will be maintained going forward. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to document procedures for the response to unusual incidents.
The policy and procedures manual was reviewed on June 10-12, 2019. The manual did not include the required documentation of procedures for 709.34 (a)(1-8).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Alpha House believed it was in compliance with the written policy and procedure. Upon learning that the written procedure did not comply with 28 Pa Code 709.34, Alpha House has begun updating the written policy and procedure to include more detailed procedural language, following the outline and requirements of 28 Pa Code 709.34.
The procedure is being updated to document the "who, how and when" procedures for responding to the unusual incidents laid out in 709.34 (a) (1-8):
Physical assault or sexual assault by staff or a client.
Selling or use of illicit drugs on the premises.
Death or serious injury due to trauma, suicide, medication error or unusual
circumstances while in residential treatment or, when known by facility, for ambulatory
services.
Significant disruption of services due to disasters such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
Theft, burglary, break-in or similar incident at the facility.
Event at the facility requiring the presence of police, fire or ambulance personnel.
Fire or structural damage to the facility
Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
An example of how Alpha House is drafting more detailed language within their procedures is detailed below for 709.34 (a) (3) - Medication Error:
In the case of a medication error, the highest ranking staff on premises will be immediately alerted to assist and assess the situation. Upon assessment, staff shall notify the appropriate parties. If the highest level staff believe it is non-life-threatening, poison control will be called to confirm, and recommendations will be documented, charted and followed. If a serious medication error is assessed, ambulatory services will be called and the client's status monitored. The Residential Director and Executive Director will be notified of an unusual incident within 24 hours of occurrence, an internal incident report will be completed by the staff member(s) present, and filed confidentially with the Executive Director. If appropriate, and as allowed by state and federal law, DDAP will be notified of the unusual incident within three days.
Alpha House shall review and identify the causes directly or indirectly responsible for the unusual incident. This may include, but is not limited to, staff and client interviews, review of documentation, and evaluation of medication oversight processes. This review and identification process shall be completed within 5 business days.
When indicated, a corrective action plan will also be drafted within 5 business days of Residential and/or Executive Director notification and implemented immediately upon completion. Under the direction of the Executive Director, the Residential Director will initiate appropriate ongoing monitoring of an indicated corrective action plan.
Any and all reporting of unusual incidents to an entity shall be in compliance with State and Federal confidentiality laws, such as those within 4 Pa Code 255.5.
Alpha House staff has been notified of the necessary changes, providing more detailed procedural requirements, as reflected in the meeting minutes on 06/27/2019 and 07/11/2019.
Alpha House will have a finalized, detailed, written Procedure for 709.43 (a) (1-8) on or before 08/31/2019.
Executive Director will provide staff with copies of the fully updated unusual incident procedure at the first staff meeting following finalization of the written procedure. This will be evidenced in future staff meeting minutes. |