INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29-30, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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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(iv) Outdated drugs are removed.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 review of medication storage inspection logs, the facility failed to document inspections of the storage area at least quarterly, as per agency policy.
The medication storage inspection logs were requested on July 29, 2021. There were no inspections of the medication storage area documented for the time period reviewed - January - July 2021. An inspection was conducted while the licensing specialist was onsite, July 29, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medication inspection log shall be conducted quarterly per agency policy.
The medication inspection log will be conducted by staff quarterly, under the supervision of the Director of Operations.
The inspection for this quarter was conducted on 7/29/2021. The next medication inspection log will be completed on or before 10/31/2021. |
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 within 7 days of discharge, as per agency policy, in two of six client records.
Client #5 was admitted on March 5, 2021 and discharged on May 21, 2021. There was no follow up documented for client #5.
Client #6 was admitted on April 26, 2021 and discharged on June 16, 2021. There was no follow up documented for client #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow-up note shall be completed by clinical staff within 7-days of discharge, per agency policy.
Follow-up notes are the responsibility of the counselor assigned to the individual case, under the supervision of the Director of Operations.
The Director of Operations will conduct monthly chart reviews starting September 2021. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in two of two client records.
Client #1 was admitted on March 22, 2021 and discharged on April 5, 2021. There was no discharge summary documented for client #1.
Client #2 was admitted on March 25, 2021 and discharged on April 5, 2021. There was no discharge summary documented for client #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The discharge summary shall be conducted by clinical staff per agency policy.
Discharge summaries are the responsibility of the counselor assigned to the individual case, under the supervision of the Director of Operations.
The Director of Operations will conduct monthly chart reviews beginning September 2021. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up within 7 days of discharge, as per agency policy, in two of two client records.
Client #1 was admitted on March 22, 2021 and discharged on April 5, 2021. There was no follow up documented for client #1.
Client #2 was admitted on March 25, 2021 and discharged on April 5, 2021. There was no follow up documented for client #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The follow-up note shall be completed by clinical staff within 7-days of discharge, per agency policy.
Follow-up notes are the responsibility of the counselor assigned to the individual case, under the supervision of the Director of Operations.
The Director of Operations will conduct monthly chart reviews starting September 2021 |