INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Alternative Counseling Associates, 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 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, conducted on 9/18/17 between 1:00 pm and 2:00 pm, the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety as evidenced by the following:
1)The back porch of the facility had several floor boards that were rotten and noticeably sank down when stepped on.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The Executive Director assumes responsibility for this citation and the future monitoring of its compliance.
Ten loose boards were removed on 9/26/2017 by maintenance replaced with pressure treated two by six boards and screwed down with galvanized wood screws securely. The porch was also painted to reduce additional weather wear. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection conducted on 9/18/17, it was discovered that the facility failed to maintain client records in locked storage containers at all times. Two client ' s records were found in an unlocked and unoccupied counselor's office.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director assumes responsibility for this citation and future monitoring of its compliance.
Counselors will be responsible for returning all files to the appropriate file cabinets at the end of the day to be locked up. Throughout the day, counselors will be responsible to lock their office doors, or lock client files being used during the day in locked closets in their offices or both whenever they are not physically in their offices. No files are permitted in their offices overnight or leave the premises as per policy and procedures. All counselors have been provided keys to the necessary file cabinets. A review of confidentiality policies and procedures was conducted on 9/28/2017 in a clinical staff meeting. Staff personnel were issued and read a memo regarding the policy on confidentiality and initialed the document indicating that they read and understand it. |