INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7-8, 2020 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, Alpine Springs Linesville LLC DBA 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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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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client that complied with 4 Pa Code 255.5 in six of seven client records.
Client records # 2, 3, 4, 5, 6 and 7 documented specific information to be disclosed that exceeded 4Pa Code 255.5 for a potential third-party payor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director and Lead Admissions person met with all Admissions Department staff on 12/23/2020 and trained them on PA 255.5 and how to correctly complete releases of information. The Admissions Lead will monitor future ROI's for correctness in compliance with PA 255.5 |
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(iv) Outdated drugs are removed.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 the review of administrative documentation, the facility failed to document at least quarterly inspections.
The administrative documentation was reviewed for the time period of February 2020 to November 2020. There was no documentation of at least quarterly inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Nurse and Program Technician Supervisor developed an Excel spreadsheet to track these medications. The Lead Nurse will supervise the process of Program Technician Supervisor ensuring the Medication Technician tracks all medications quarterly. Tracking sheets will be kept in a binder at each facility. |