INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24 - 25, 2022 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 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. The following deficiencies were identified during this inspection:
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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 Staffing Requirements Facility Summary Report (SRFSR) and an interview with project/facility director, the facility failed to maintain a minimum of one FTE (full time equivalent) primary care staff person for every seven clients during primary care hours.
Primary care hours for the detoxification activity are 24 hours per day, 7 days per week.
Per the SRFSR, the facility only had one primary care staff person providing coverage from 3 PM - 7 AM on the following dates. Based on the daily census, two primary care staff would have been required.
December 26, 2021 - census 8 clients
December 28, 2021 - census 8 clients
December 29, 2021 - census 10 clients
December 30, 2021 - census 8 clients
December 31, 2021 - census 9 clients
January 1, 2022 - census 10 clients
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director had respectfully submitted a Request for Exception letter, to DDAP licensure, on 2/3/2022. That request was denied.
Therefore, we will adhere to the Alert. We will continue to pursue the immediate hire of staff that qualify as primary care staff in the Alert. Our goal is to hire primary care staff immediately if possible, but within 90 days of today's date. The HR Director is responsible for recruitment and hiring of the primary care staff. The HR Director is responsible for hiring and maintaining primary care staff so the deficiency does not re-occur. The Operations Director will ensure primary care staff are scheduled according to the 7:1 ratio. The Project Director will also monitor HR and that primary care staff hiring occurs asap. |
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
Based on a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be disclosed to the funding entity on the consent to release information form in seven of seven records.
The consent to release information forms were documented during the intake process and indicated the discharge summary and continuing care plan/transition plan would be release to the funding entity in the following client records:
Client # 1 was admitted January 16, 2022.
Client # 2 was admitted January 18, 2022.
Client # 3 was admitted January 19, 2022.
Client # 4 was admitted June 2, 2021 and discharged June 6, 2021. The consent to release information form for client # 4 also indicated the treatment plan, treatment plan updates and medications would be released to the funding entity.
Client # 5 was admitted June 21, 2021 and discharged June 25, 2021.
Client # 6 was admitted June 9, 2021 and discharged June 14, 2021.
Client # 7 was admitted December 24, 2021 and discharged December 28, 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 7 - 8, 2020 licensing inspection.
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Plan of Correction
Since the inspection date, the Project Director met with nursing staff, clinical staff, and Admissions staff.
All of the above staff were formally trained on PA 255.5, how to properly fill out the ROI.
Staff Training was documented and given to HR.
The Project Director will monitor documentation / ROI's by nursing, clinical, admissions staff to ensure compliance with PA 255.5 going forward. |
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
Based on a review of client records, the facility failed to document a written consent to release information form that included the purpose of disclosure in four of seven client records.
The consent to release information forms for a treatment provider were documented during the intake process and indicated the purpose of disclosure was the "release of information".
Client # 1 was admitted January 16, 2022.
Client # 2 was admitted January 18, 2022.
Client # 3 was admitted January 19, 2022.
Client # 7 was admitted December 24, 2021 and discharged December 28, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the inspection date, the Project Director met with nursing staff, clinical staff, and Admissions staff.
All of the above staff were formally trained on PA 255.5, how to properly fill out the ROI.
This training specifically included inclusion of the "purpose of disclosure" and acceptable purposes for disclosure.
Staff Training was documented and given to HR.
The Project Director will monitor documentation / ROI's by nursing, clinical, admissions staff to ensure compliance with 255.5 / the purpose of disclosure, going forward. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection, review of medication documentation and facility staff interviews, the facility failed to document quarterly inspections of the medication storage area from January 2021 through December 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 7 - 8, 2020 licensing inspection.
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Plan of Correction
Project Director updated the MED-15 Policy to include the specific items required on this POC item. Also developed a form to track said items (quarterly). This form was given to the lead nurse to complete the quarterly inspection (at each facility) by the first week of Feb. 22. Staff nurse completed the medication inspections on Feb. 4 (Jamestown facility) and Feb. 7 (Linesville facility), 2022. The lead nurse will be responsible for monitoring that all quarterly medication inspections are completed and documented on the approved form. |