INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 2, an abbreviated on-site inspection, conducted on January 6, 2021 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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:
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Plan of Correction
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to store all trash in covered containers that prevent the penetration of insects and rodents. Trash cans were observed to be overflowing and without lids.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The trash cans have been replaced with receptacles that have attached lids. This makes them easier to ensure coverage, and prevent the loss of lids. Additionally, the number of trash cans has also been increased to ensure that all bags are able to be contained and covered appropriately in a bin. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain bathrooms in a clean and sanitary manner. The second-floor bathroom sick was dirty. The sink was cleaned prior to the end of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The cleaning of the bathrooms is going to be reviewed more closely by staff and resident house manager to ensure they maintain a level of cleanliness that is acceptable or exceeds licensing standards. The sink in question has been covered in a black bag to prevent the usage as it is a sink that is not in use but is cost prohibitive to remove. This a short-term fix as we are going to build a cover over the sink so that there will not any opportunity for potential use. |
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 failed to document a completed consent to release information form that included what specific information could be disclosed in one out of fourteen client records reviewed.
Client #8 was admitted on August 27, 2020 and discharged on October 8, 2020. The consent form was dated June 30, 2020 from a previous admission and was for the funding source.
The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the June 10-12, 2019 licensing inspection.
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Plan of Correction
Client #8 was admitted on 6/30/2020 and discharged on 10/8/2020. The Release did not have the specific information to be released documented on it. Going forward all releases will be reviewed by the Clinical Director prior to filing and reviewed quarterly by the Director of Operations for completeness and accuracy. Findings will be documented and reported to CEO.
Staff will also be re-trained on completing the Release of Information in its entirety by 3/17/2021 to ensure that they have a full understanding of the need for full and appropriate completion, and the liability if it is not fully completed.
Also, a template has been created that will allow for the quick review of the Releases going forward. It is a blank Release with the required areas cut out to ensure that there is an answer in those spots.
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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
Based on the review of client records, the facility failed to document a completed consent to release information form that included a purpose of disclosure in four out of fourteen client records reviewed.
Client #3 was admitted on April 22, 2020 and was still active at the time of the inspection. A consent form dated April 22, 2020 was to the funding source.
Client #5 was admitted on July 1, 2020 and discharged on September 1, 2020. A consent form dated July 1, 2020 was to the funding source.
Client #7 was admitted on March 4, 2020 and discharged on December 7, 2020. A consent form dated August 12, 2020 was to the funding source.
Client #8 was admitted on August 27, 2020 and discharged on October 8, 2020. A consent form dated June 30, 2020 from a previous admission was to the funding source.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the June 10-12, 2019 licensing inspection.
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Plan of Correction
Client #3 was admitted on 4/22/2020. The Release did not have the specific information to be released documented on it. Going forward all releases will be reviewed by the Clinical Director prior to filing and reviewed quarterly by the Director of Operations for completeness and accuracy. Findings will be documented and reported to CEO.
Client #5 was admitted on 7/1/2020 and discharged on September 1, 2020. The Release did not have the specific information to be released documented on it. Going forward all releases will be reviewed by the Clinical Director prior to filing and reviewed quarterly by the Director of Operations for completeness and accuracy. Findings will be documented and reported to CEO.
Client #7 was admitted on 8/12/2020 and discharged on December 8, 2020. His funding source release was dated upon admission. The Release did not have the specific information to be released documented on it. Going forward all releases will be reviewed by the Clinical Director prior to filing and reviewed quarterly by the Director of Operations for completeness and accuracy. Findings will be documented and reported to CEO.
Client #8 was admitted on 6/30/2020 and discharged on 10/8/2020. The Release did not have the specific information to be released documented on it. Going forward all releases will be reviewed by the Clinical Director prior to filing and reviewed quarterly by the Director of Operations for completeness and accuracy. Findings will be documented and reported to CEO.
In addition to the plans of correction above, a template has been created that will allow for the quick review of the Releases going forward. It is a blank, laminated Release with the required areas cut out to ensure that there is an answer in the required spots.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form that included a signature from the client in one out of fourteen records reviewed.
Client #2 was admitted on November 16, 2020 and was still active at the time of the inspection. Two consent forms dated November 16, 2020 were to another facility and a government agency.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #2 was admitted on 10/5 and a consent for Crossroads Treatment Center was in the file, this is not a consent that should be in there as the client does not receive services at Crossroads. Counselor who completed this has been educated on completing releases that are appropriate for the care that they receive rather than blanket releases.
Client #2 also had another unsigned release due to his services being provided via telehealth. Going forward, Releases will be mailed and a self-addressed stamped envelope will be included for the client to sign and return the release. This will be noted in the releases section of the file as reminder that it was sent. Until the release is returned signed the Counselor will not be able to have communication with the person or entity.
These procedures have been reviewed with all applicable staff and signed off that they understand.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information form that include a witness signature in one out of fourteen client records reviewed.
Client #8 was admitted on August 27, 2020 and discharged on October 8, 2020. The consent form dated August 10, 2020 was to a medical facility.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #8 was admitted on 6/30/2020 has a release for a medical practice dated 8/10/2020 that the allows Alpha House to release if the client is in treatment or not. This release was completed after admission as he was referred for additional treatment by his PCP.
The Counselor forgot to witness the release/date the signature and has been educated on this.
All releases will be reviewed for completeness by the Clinical Director prior to filing and reviewed quarterly by the Director of Operations for completeness and accuracy. Finding will be documented and given to CEO.
Also, a template has been created that will allow for the quick review of the Releases going forward. It is a blank Release with the required areas cut out to ensure that there is an answer in those spots.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form indicating if the client had been offered a copy in two out of fourteen client records reviewed.
Client #2 was admitted on November 16, 2020 and was still active at the time of the inspection. Three consent forms dated November 16, 2020 were to another facility, a government agency, and a family member.
Client #9 was admitted on September 18, 2020 and discharged on November 28, 2020. A consent form dated September 18, 2020 was to a pharmacy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 was admitted on 11/16/2020, the Releases dated 11/16/2020 were not marked if a copy was provided or not to the client. The staff has been educated on ensuring this is completed. This also will be followed up on by the Clinical Director reviewing all releases prior to filing and the Director of operations reviewing all releases quarterly. Any findings will be documented and given to CEO.
Client #9 Client #2 was admitted on 09/18/2020, the Releases dated 09/19/2020 were not marked if a copy was provided or not to the client. The staff has been educated on ensuring this is completed. This also will be followed up on by the Clinical Director reviewing all releases prior to filing and the Director of operations reviewing all releases quarterly. Finding will be documented and given to CEO.
Again, the template has been created that will allow for the quick review of the Releases going forward. It is a blank Release with the required areas cut out to ensure that there is an answer in those spots.
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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgement by the client that the client had been aware of their rights in thirteen out of thirteen client records reviewed. The facility did not notify the client that they may not be discriminated against based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Client #1 was admitted on August 3, 2020 and was still active at the time of the inspection.
Client #2 was admitted on November 16, 2020 and was still active at the time of the inspection.
Client #3 was admitted on April 22, 2020 and was still active at the time of the inspection.
Client #4 was admitted on September 7, 2020 and discharged on October 14, 2020.
Client #5 was admitted on July 1, 2020 and discharged on September 1, 2020.
Client #7 was admitted on March 4, 2020 and discharged on December 7, 2020.
Client #8 was admitted on August 27, 2020 and discharged on October 8, 2020.
Client #9 was admitted on September 18, 2020 and discharged on November 28, 2020.
Client #10 was admitted on October 8, 2020 and was still active at the time of the inspection.
Client #11 was admitted on July 17, 2020 and was still active at the time of the inspection.
Client #12 was admitted on October 8, 2020 and was still active at the time of the inspection.
Client #13 was admitted on September 11, 2020 and was discharged on December 8, 2020.
Client #14 was admitted on August 10, 2020 and discharged on November 9, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The client handbook was reviewed and the Client Rights has been updated to include the 13 rights and that the project may not discriminate the services provided based on these rights.
The Residents Rights section of the Handbook has been updated, all old handbooks have been destroyed, and the residents retained in care were provided with the new version and signed off on them on 3/2/2021.
The new handbook will be distributed to all new admissions going forward.
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