INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16-18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Angel ' s Light Addiction Specialists 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to document that staff persons completed HIV/AIDS and/or TB/STD training within the required timeframes in three of five personnel records.
Staff #8 was hired as a counselor assistant on March 20, 2023. HIV/AIDS and TB/STD training were due to be completed by March 20, 2024. There was no HIV/AIDS training documented in staff record #8.
Staff #10 was hired as a support staff on January 1, 2022. HIV/AIDS and TB/STD training were due to be completed by January 1, 2024. There was no TB/STD training documented in staff record #10.
Staff #11 was hired as a support staff on April 9, 2021. HIV/AIDS and TB/STD training were due to be completed by April 9, 2023. There was no TB/STD training documented in staff record #11.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. The Project Director will review with the Clinical Director and Tech Supervisor that they are responsible for monitoring their supervisee's training topics and hours required. |
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, the facility failed to keep the grounds of the facility, clean, safe, in good repair and free of hazards at all times.
A physical plant inspection was conducted on April 16, 2024 at approximately 10:00 AM.
At the time of the inspection, potholes and cracks were observed in the parking lot and driveway.
A window in client bedroom #7 was observed to have a cracked frame with sharp edges.
Client bedrooms #10 and #11 were observed to have holes in their doors.
Client bedroom #13 was observed to have a hole in the wall.
A counselor office by the back door was observed to have a broken door frame with protruding nails and exposed broken wood with sharp edges.
In addition, the client male bathroom sink (right) was observed to have a large crack. One of the shower floors in the male client bathroom was observed to be damaged with chips in the surface.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light Addiction Specialists previous hired contractor to fill in cracks/potholes in the facility driveway/parking lot. Contracting Servicer filled potholes and cracks in parking lot/driveway on 4/16/24.
The window in client bedroom #7 that had a cracked frame with sharp edges was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24. The contractor stabilized cracked frame and filled crack on bedroom window #7.
Client bedrooms #10 and #11 holes in the doors were resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24. New doors were placed in bedrooms #10 & #11.
Client bedroom #13 had a hole in the wall that was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24. The contractor patched the hole in the wall in bedroom #13.
The counselor's office by the back door that had a broken frame with protruding nails and exposed broken wood with sharp edges was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24. The contractor placed a new door and door frame into the counselor's office by the back door.
The male bathroom (right) sink with a large crack was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24. Contractor filled crack in the sink.
The male shower floor that was observed with chips in the surface was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24. The contractor refinished the shower floor surface removing the chips in the surface of the floor.
The Project Director has reviewed with the tech department that upon room check completions, they are to observe the facility for damages, and report any damages to their supervisor for appropriate corrective actions to be taken to repair damages.
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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, the facility failed to store trash, garbage and rubbish in a covered container that prevents the penetration of insects and rodents.
A physical plant inspection was conducted on April 16, 2024 at approximately 10:00 AM. At the time of the inspection, the dumpster was observed to be open with trash bags visible.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light Quality Assurance has posted a visible sign on the side of the building where the facility dumpster is located on 4/18/24. The sign reminds staff and clients of the importance of keeping the lid to the dumpster closed to prevent the penetration of insects and rodents. Department supervisors were made aware and have communicated with their department staff to frequently check the building exterior and grounds during smoke breaks, shift rounds, etc. to enforce and ensure compliance with required licensing regulations effective 4/20/2024. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain counseling areas with furnishings in good repair.
A physical plant inspection was conducted on April 16, 2024 at approximately 10:00 AM. At the time of the inspection, one of the chairs in the group room was found to have a seat cushion that was ripped and damaged at the corners.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The seat cushion with ripped and damaged corners was resolved on 6/20/24. The ripped and damaged seat cushion was removed and replaced with another seat cushion that is undamaged. The Project Director reviewed with the Clinical Director and Tech Manager the importance of reminding staff to report any facility property damage to their direct supervisor. The Clinical Director and Tech Manager will report facility damage and/or wear and tear to the Project Director in writing for any needed repairs to be scheduled promptly to adhere with licensing regulations. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees.
A physical plant inspection was conducted on April 16, 2024 at approximately 10:00 AM.
At the time of the inspection, the water temperature in the male client bathroom was observed to be 165 degrees.
The female client bathroom was observed to be 145 degrees, and the male staff bathroom was observed to be 130 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The female client's bathroom hot water observed to be 145 degrees was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24 who adjusted the heating value for the hot water tank.
The hot water in the male client's bathroom observed to be 165 degrees was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24 who adjusted the heating valve for the hot water tank.
The male staff bathroom's hot water observed to be 130 degrees was resolved on 6/20/24 by a licensed contractor hired by the facility on 6/19/24 who adjusted the heating valve for the hot water tank.
The Tech Supervisor will be responsible monthly to check the hot water temperature in all facility restrooms and report any needed repairs to the Project Director.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel and training records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment.
Staff #2 was hired as the facility director on April 1, 2024. The documentation provided states that Staff #2 was not trained in the use of fire extinguishers until April 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director met with department supervisors to discuss their responsibility of training their new hire department staff in emergency procedures within the first week of employment. ALAS Quality Assurance has sent an onboarding email that can be referenced back to, to the tech supervisor and clinical director about what is required for new hires to ensure compliance in training requirements for ALAS staff. ALAS Quality Assurance effective 6/20/24 is responsible for ensuring emergency procedures (fire safety/extinguisher trainings) are completed with new hires within the 1st week of employment. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel and training records, the facility failed to instruct all staff in emergency procedures upon staff employment.
Staff #2 was hired as the facility director on April 1, 2024. The documentation provided states that Staff #2 was not trained in emergency procedures until April 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director met with department supervisors to discuss their responsibility of training their new hire department staff in emergency procedures within the first week of employment. ALAS Quality Assurance has sent an onboarding email that can be referenced back to, to the tech supervisor and clinical director about what is required for new hires to ensure compliance in training requirements for ALAS staff. ALAS Quality Assurance effective 6/20/24 is responsible for ensuring emergency procedures (fire safety/extinguisher trainings) are completed with new hires within the 1st week of employment. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs, the facility failed to maintain fire drill records which included the time it took for evacuation.
The fire drill logs for October 2023 - March 2024 were reviewed. There were no times for evacuation documented for the fire drills conducted on November 20 and December 8, 2023 and January 16, February 3, and March 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light Quality Assurance has revised the fire drill/event form to include in the record: the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. ALAS Quality Assurance has implemented the new fire drill form effective 7/1/24. ALAS QA reviewed new form with department supervisors on 7/1/24. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of a signed informed and voluntary consent to disclose information to a funding source in client record #1. It was confirmed that services were billed for this client.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of a signed informed and voluntary consent to disclose information to a funding source in client record #6. It was confirmed that services were billed for this client.
Client #8 was admitted on March 24, 2024 and is currently active in treatment. There was no documentation of a signed informed and voluntary consent to disclose information to a funding source in client record #8. It was confirmed that services were billed for this client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Clinical Department has undergone recent staff changes to rebuild licensing compliance. All current Clinical and Admission staff will attend or reattend the Substance Use Disorder Confidentiality On-Demand training via tms/keystone account on or by 8/16/2024. ALAS Quality Assurance will track the staff member trainings to ensure all staff comply by the timeframe of 8/16/24. ALAS Quality Assurance will conduct monthly chart audits to monitor compliance. All admissions staff have been retrained on the importance of completing a signed informed and voluntary consent upon admission for client funding sources on 6/30/24. Client funding source consents have been added to client admission packets to ensure compliance upon admission effective 6/30/24. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client, which included the person/agency/entity to whom disclosure is made, in one of eight client records.
Client #8 was admitted on March 24, 2024 and is currently active in treatment. There was no documentation of an informed and voluntary consent, which included the person/agency/entity to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Clinical Department has undergone recent staff changes to rebuild licensing compliance. All current Clinical and Admission staff will attend or reattend the Substance Use Disorder Confidentiality On-Demand training via tms/keystone account on or by 8/16/24. ALAS Quality Assurance will track the staff member trainings to ensure all staff comply by the timeframe stated. ALAS Quality Assurance will re-review with clinical and admission staff the consent forms to ensure compliance regarding to whom disclosure is made. Clinical and admission staff will be retrained by ALAS Quality Assurance on 7/29/24. |
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 obtain an informed and voluntary consent from the client, which included the specific information to be disclosed, in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. A signed consent to release information to a family member was documented in the client record; however, it did not include the specific information to be disclosed.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. Signed consents to release information to the jail, probation and pretrial services were documented in the client record; however, they did not include the specific information to be disclosed.
Client #8 was admitted on March 24, 2024 and is currently active in treatment. A signed consent to release information, that did not indicate a recipient, was documented in the client record; however, it did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Clinical Department has undergone recent staff changes to rebuild licensing compliance. All current Clinical and Admission staff will attend or reattend the Substance Use Disorder Confidentiality On-Demand training via tms/keystone account on or by 8/16/24. ALAS Quality Assurance will track the staff member trainings to ensure all staff comply by the timeframe stated. ALAS Quality Assurance will re-review with clinical and admission staff the consent forms to ensure compliance regarding specific information to be disclosed. Clinical and admission staff will be retrained by ALAS Quality Assurance on 7/29/24. |
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 obtain an informed and voluntary consent from the client, which included the purpose of disclosure, in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. A signed consent to release information to a family member was documented in the client record; however, it did not include the purpose of the disclosure.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. Signed consents to release information to the jail, probation and pretrial services were documented in the client record; however, they did not include the purpose of the disclosure.
Client #8 was admitted on March 24, 2024 and is currently active in treatment. A signed consent to release information, that did not indicate a recipient, was documented in the client record; however, it did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Clinical Department has undergone recent staff changes to rebuild licensing compliance. All current Clinical and Admission staff will attend or reattend the Substance Use Disorder Confidentiality On-Demand training via tms/keystone account on or by 8/16/24. ALAS Quality Assurance will track the staff member trainings to ensure all staff comply by the timeframe stated. ALAS Quality Assurance will re-review with clinical and admission staff the consent forms to ensure compliance regarding the purpose of disclosure. Clinical and admission staff will be retrained by ALAS Quality Assurance on 7/29/24. |
709.30 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.
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Observations
Based on a review of client records, the facility failed to document a written acknowledgement of client rights in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of a signed client rights acknowledgement in client record #1.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of a signed client rights acknowledgement in client record #6.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. There was no documentation of a signed client rights acknowledgement in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Clinical Department has undergone recent staff changes to rebuild licensing compliance. All current Clinical and Admission staff will attend or reattend the Substance Use Disorder Confidentiality On-Demand training via tms/keystone account on or by 8/16/2024. ALAS Quality Assurance will track the staff member trainings to ensure all staff comply by the timeframe of 8/16/24. ALAS Quality Assurance will conduct monthly chart audits to monitor compliance. All admissions staff have been retrained on the importance of completing a signed clients right acknowledgement form. Client rights acknowledgement forms have been added to client admission packets to ensure compliance upon admission effective 6/30/24. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
Based on a review of the policy and procedure manual and staff interviews, the facility failed to document written policies and procedures for medication control which includes staff responsibilities and the administration of medication.
The medication control policy and procedure did not include documentation of who, by job title, is responsible for the administration of medication, inspection of medication storage areas, methods of control and accountability of drugs, the security of drugs and medication areas and drug reactions.
There was no documentation of a medication administration policy or procedure which detailed the manner in which medications are administered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Project Director and Quality Assurance will revise the medical control policy on or before 7/20/24 to include documentation of who, by job title, is responsible for the administration of medication, inspection of medication storage areas, methods of control and accountability of drugs, the security of drugs and medication areas and drug reactions. The revision will also include the manner in which medications are administered. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to document that medications were administered as prescribed in two of seven client records.
There was no medication administrative policy documented to review to determine how medication administration is completed and recorded. There were medication administration records (MARs) documented in some of the client records reviewed; however, there is no uniformity in the completion of them. In addition, there is no key attached to MARs, making the one letter entries unclear as to whether the medication was administered or not.
Client #5 was admitted on March 7, 2024 and discharged on April 8, 2024. A physical examination was conducted on March 7, 2024 which stated the client was to continue two medications, one that was to be taken one time at bedtime and the other that was to be taken twice per day. There was no medication administration record documented in client record #5.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. Client #7 was prescribed a medication for one tablet to be taken every morning. Per the MAR, the client did not receive the medication as prescribed from February 6 - February 26, 2024.
A second medication was prescribed for two tablets to be taken daily at bedtime. Per the MAR, the client did not receive the medication as prescribed on February 1, 2, 4, 7, 10, 11, 12, 13, 17, & 24, 2024.
A third medication was prescribed for one tablet to be taken every night. Per the MAR, the medication was not given as prescribed on February 1-2, 2024. The medication was given in the morning on February 8-26, 2024. In addition, the medication was given twice on one day on February 10, 2024.
A fourth medication was prescribed for one strip to be taken twice per day. Per the MAR, the medication was not given as prescribed on February 8, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Project Director will retrain staff members who observed medication pass on documentation. To prevent reoccurrence, education will include utilization of the backside of the MAR sheet to document med refusals and the tech manager will be responsible for randomly completing MAR audits to ensure compliance etc. Training will be completed by 8/9/24. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports, the facility failed to file a report with DDAP within 3 business days following an event at the facility requiring the presence of police, fire or ambulance personnel.
An incident occurred on December 7, 2023 in which the police were contacted and reported to the facility. There was no documentation that an unusual incident report was filed with DDAP within 3 business days.
An incident occurred on February 24, 2024 in which the ambulance was contacted and reported to the facility. There was no documentation that an unusual incident report was filed with DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will file an electronic written unusual incident report with the department within 3 business days following an unusual incident involving the presence of police, fire or ambulance personnel effective 7/1/24. ALAS Quality Assurance will randomly audit for unusual incident report binder to have print outs as evidence of reporting updated to show compliance on site. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission, treatment completion and discharge in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of client disclosure for the criteria for admission, treatment completion and discharge in client record #1.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of client disclosure for the criteria for admission, treatment completion and discharge in client record #6.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. There was no documentation of client disclosure for the criteria for admission, treatment completion and discharge in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client disclosure documentation is included within the admission packet in our electronic system ensuring compliance moving forward with documentation of client disclosure for the criteria for admission, treatment completion and discharge the document effective 6/28/24. ALAS Quality Assurance will be responsible for completing monthly random admission audits to ensure compliance. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, that included familiarization with project policies, in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of client orientation to the project, that included familiarization with project policies, in client record #1.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of client orientation to the project, that included familiarization with project policies, in client record #6.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. There was no documentation of client orientation to the project, that included familiarization with project policies, in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client orientation to the project, that includes familiarization with project policies is included within the admission packet in our electronic system ensuring compliance moving forward with the document effective 6/28/24. ALAS Quality Assurance will be responsible for completing monthly random admission audits to ensure compliance. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, that included hours of operation, in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of client orientation to the project, that included hours of operation, in client record #1.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of client orientation to the project, that included hours of operation in client record #6.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. There was no documentation of client orientation to the project, that included hours of operation, in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client orientation to the project, which includes hours of operation within the admission packet in our electronic system ensuring compliance moving forward with the document effective 6/28/24. ALAS Quality Assurance will be responsible for completing monthly random admission audits to ensure compliance. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, that included the fee schedule, in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of client orientation to the project, that included the fee schedule, in client record #1.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of client orientation to the project, that included the fee schedule, in client record #6.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. There was no documentation of client orientation to the project, that included the fee schedule, in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client orientation to the project, which includes the fee schedule is within the admission packet in our electronic system effective 6/28/24. A daily fee schedule is also located in 3 different spots in the facility (admission/intake office, by client telephone, and in client kitchen area) effective 6/28/24. ALAS Quality Assurance will monitor in random chart audits of signature of acknowledgement in admission packet regarding orientation to the project and the fee schedule. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project, that included the services provided, in three of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of client orientation to the project, that included the services provided, in client record #1.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of client orientation to the project, that included the services provided, in client record #6.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. There was no documentation of client orientation to the project, that included the services provided, in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client orientation to the project, that includes the services provided within the admission packet is in our electronic system effective 6/28/24. ALAS Quality Assurance will monitor in random chart audits monthly of signature of acknowledgement in admissions packet. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in six of eight client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. There was no documentation of a preliminary treatment plan discharge in client record #1.
Client #2 was admitted on March 8, 2024 and discharged on March 27, 2024. There was no documentation of a preliminary treatment plan discharge in client record #2.
Client #3 was admitted on February 29, 2024 and is currently active in treatment. There was no documentation of a preliminary treatment plan discharge in client record #3.
Client #5 was admitted on March 7, 2024 and discharged on April 8, 2024. There was no documentation of a preliminary treatment plan discharge in client record #5.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of a preliminary treatment plan discharge in client record #6.
Client #8 was admitted on March 24, 2024 and is currently active in treatment. There was no documentation of a preliminary treatment plan discharge in client record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The admission department will be responsible for completing the preliminary treatment plan with the client upon admission to the facility effective 6/28/24. ALAS Quality Assurance will monitor compliance during random monthly chart audits. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility ' s policy and procedures, the facility failed to document an individual treatment and rehabilitation plan with the client in four of eight client records.
The facility ' s policy states that the individual treatment and rehabilitation plan shall be developed with the client within three days of the initial session.
Client #2 was admitted on March 8, 2024 and discharged on March 27, 2024. There was no initial session documented and there was no documentation of an individualized treatment and rehabilitation plan in client record #2.
Client #3 was admitted on February 29, 2024 and is currently active in treatment. There was no initial session documented and there was no documentation of an individualized treatment and rehabilitation plan in client record #3.
Client #5 was admitted on March 7, 2024 and discharged on April 8, 2024. The initial session was documented on March 15, 2024 and the individualized treatment and rehabilitation plan was due to be completed by March 18, 2024. There was no documentation of an individualized treatment and rehabilitation plan in client record #5.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. The initial session was documented on January 23, 2024 and the individualized treatment and rehabilitation plan was due to be completed by January 26, 2024. There was no documentation of an individualized treatment and rehabilitation plan in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Quality Assurance will meet with and retrain clinical staff on documentation regarding compliance and per policy. Clinical staff will be reeducated on 7/29/24. ALAS Quality Assurance will monitor compliance during random monthly chart audits. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records and facility policy and procedures, the facility failed to document treatment plan updates every fifteen days, as required by policy and regulation, in three of three client records.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. The individual treatment and rehabilitation plan was documented on January 17, 2024 and a treatment plan update was completed on February 1, 2024. Additional treatment plan updates were due to be completed by February 16 and March 1, 2024. There were no additional treatment plan updates documented in client record #1.
Client #4 was admitted on March 5, 2024 and is currently active in treatment. The individual treatment and rehabilitation plan was documented on March 7, 2024 and a treatment plan update was completed on March 22, 2024. Additional treatment plan updates were due to be completed by April 6, 2024. There were no additional treatment plan updates documented in client record #4.
Client #8 was admitted on March 24, 2024 and is currently active in treatment. The individual treatment and rehabilitation plan was documented on March 26, 2024. A treatment plan update was due to be completed by April 10, 2024. There were no additional treatment plan updates documented in client record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Quality Assurance will meet with and retrain clinical staff on documentation regarding compliance and per policy. Clinical staff will be reeducated on 7/29/24. ALAS Quality Assurance will monitor compliance during random monthly chart audits. Clinical is responsible for completing the treatment plan review every 15 days. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide counseling services as per the individual treatment and rehabilitation plan in two of four client records.
Client #4 was admitted on March 5, 2024 and is currently active in treatment. The individual treatment and rehabilitation plan was documented on March 7, 2024, and included that the individual sessions were to be provided weekly and group sessions daily. There was no individual session documented for the week of March 31st, 2024.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. The individual treatment and rehabilitation plan was documented on February 2, 2024, and included that the individual sessions were to be provided weekly and group sessions daily. There was no individual session documented for the week of February 4th, February 11th, February 18th, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Quality Assurance will meet with and retrain clinical staff on documentation regarding compliance and per policy. Clinical staff will be reeducated on 7/29/24. ALAS Quality Assurance will monitor compliance during random monthly chart audits. Clinical is responsible for completing the individual session weekly and group notes which is held daily. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and facility policy and procedure, the facility failed to provide counseling to clients on a regular and scheduled basis in four of eight client records.
The facility policy states that client ' s will receive one hour of individual counseling per week and two hours of group counseling per week.
Client #2 was admitted on March 8, 2024 and discharged on March 27, 2024. There was no documentation of an individual session for the week of March 10, 2024 in client record #2.
Client #3 was admitted on February 29, 2024 and is currently active in treatment. There was no documentation of individual sessions for the weeks of March 3rd, March 10th, March 17th, March 24th, March 31st and April 7th, 2024 in client record #3.
Client #5 was admitted on March 7, 2024 and discharged on April 8, 2024. There was no documentation of individual sessions for the weeks of March 17th and March 24, 2024 in client record #5.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. There was no documentation of individual sessions for the weeks of January 28th, February 4th, February 11th and February 25th, 2024 in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Quality Assurance will meet with and retrain clinical staff on documentation regarding compliance and per policy. Clinical staff will be reeducated on 7/29/24. ALAS Quality Assurance will monitor compliance during random monthly chart audits. Clinical is responsible for completing the individual session weekly for one hour and group notes which is held daily for two hours. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to maintain complete client records which included all required documentation in eight of eight client records.
During the inspection, the surveyors were notified and presented with a large box of client record documentation that was not filed. In addition, there was a significant amount of documentation missing from the client records presented to surveyors during the licensing inspection, even after the documentation in the box was filed.
Client #1 was admitted on January 17, 2024 and discharged on March 6, 2024. The client record did not contain documentation of: the disclosure of admission, treatment, completion and discharge criteria, client orientation, client rights acknowledgement, consent to release information, preliminary treatment plan, treatment plan update and follow up contact.
Client #2 was admitted on March 8, 2024 and discharged on March 27, 2024. The client record did not contain documentation of: record of service, psychosocial evaluation, preliminary treatment plan, individualized treatment and rehabilitation plan, progress notes, discharge summary and follow up contact.
Client #3 was admitted on February 29, 2024 and is currently active in treatment. The client record did not contain documentation of: preliminary treatment plan, individualized treatment and rehabilitation plan and progress notes.
Client #4 was admitted on March 5, 2024 and is currently active in treatment. The client record did not contain documentation of: record of service, treatment plan updates and progress notes.
Client #5 was admitted on March 7, 2024 and discharged on April 8, 2024. The client record did not contain documentation of: medication records, preliminary treatment plan, individualized treatment and rehabilitation plan, progress notes, discharge summary and follow up.
Client #6 was admitted on January 18, 2024 and discharged on March 7, 2024. The client record did not contain documentation of: the disclosure of admission, treatment, completion and discharge criteria, consent to treatment, client orientation, client rights acknowledgement, consent to release information, client related correspondence, preliminary treatment plan, individualized treatment and rehabilitation plan, progress notes, discharge summary and follow up contact.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. The client record did not contain documentation of: the disclosure of admission, treatment, completion and discharge criteria, consent to treatment, client orientation, client rights acknowledgement, medication records, progress notes, discharge summary and follow up contact.
Client #8 was admitted on March 24, 2024 and is currently active in treatment. The client record did not contain documentation of: consent to release information, client related correspondence, preliminary treatment plan, treatment plan updates and progress notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS has implemented an electronic recordkeeping system to ensure compliance with a complete client record. ALAS Quality Assurance will monitor for the scanning of paper documents into the client's chart with 1 week of client's discharge to prevent reoccurrence. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes for treatment sessions in eight of eight client records.
Client #1 was admitted January 17, 2024 and discharged on March 6, 2024. The group notes dated January 22, 23, 26, 31 and February 1, 2024 were incomplete as the client assessment portion of the note was not documented.
Client #2 was admitted March 8, 2024 and discharged on March 27, 2024. The group notes dated March 22 & 23, 2024 were incomplete as the client assessment portion of the note was not documented.
Client #3 was admitted February 29, 2024 and is currently active in treatment. The group note dated April 16, 2024 was incomplete as the client assessment portion of the note was not documented.
Client #4 was admitted March 5, 2024 and is currently active in treatment. The group note dated March 31, 2024 was incomplete as the client assessment portion of the note was not documented.
Client #5 was admitted March 7, 2024 and discharged on April 8, 2024. The group notes dated March 14 and March 18, 2024 were observed to be blank. The group notes dated March 29, March 31 and April 8, 2024 were incomplete as the client assessment portion of the note was not documented. The individual note documented dated April 4, 2024 was incomplete as the client assessment portion of the note was not documented.
Client #6 was admitted January 18, 2024 and discharged on March 7, 2024. The group notes dated February 2, February 8 and February 12, 2024 were observed to be blank.
Client #7 was admitted January 30, 2024 and discharged on February 26, 2024. The group notes dated, February 8 and February 12, 2024 were observed to be blank.
Client #8 was admitted March 24, 2024 and is currently active in treatment. The group notes dated March 31 and April 8, 2024 were incomplete as the client assessment portion of the note was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ALAS Quality Assurance will meet with and retrain clinical staff on documentation regarding compliance and per policy. Clinical staff will be reeducated on 7/29/24. ALAS Quality Assurance will monitor compliance during random monthly chart audits. Clinical is responsible for completing progress notes in their entirety for weekly individual sessions and daily group sessions. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in four of five discharged client records.
Client #2 was admitted on March 8, 2024 and discharged on March 27, 2024. There was no discharge summary documented for client #2.
Client #5 was admitted on March 7, 2024 and discharged on April 8, 2024. There was no discharge summary documented for client #5.
Client #6 was admitted on January 18, 2024 and discharged on February 26, 2024. There was no discharge summary documented for client #6.
Client #7 was admitted on January 30, 2024 and discharged on February 26, 2024. There was no discharge summary documented for client #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angel's Light Clinical Department has undergone employee restructuring. The Project Director reviewed with the new clinical director that a discharge summary is a required document, and the clinical director will be responsible for peer chart reviews during supervision, the training of required chart documentation, and the training of new clinical staff according to ALAS policy and DDAP licensing regulation requirements. ALAS newly appointed position of quality assurance will conduct random chart audits monthly and submit findings to the Project Director. |
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 and facility policy and procedure, the facility failed to document follow up in five of five discharged records.
Per the facility policy, follow up is to be completed within twelve hours for against medical advice (AMA) discharged clients, within three days for unplanned discharges and within five days for planned discharges.
Client #1 was admitted on January 17, 2024 and discharged for successful program completion on March 6, 2024. A follow up was due to be completed by March 11, 2024. There was no follow up documented in client record #1.
Client #2 was admitted on March 8, 2024 and administratively discharged on March 27, 2024. A follow up was due to be completed by March 30, 2024. There was no follow up documented in client record #2.
Client #5 was admitted on March 7, 2024 and discharged against medical advice on April 8, 2024. A follow up was due to be completed by April 9, 2024. There was no follow up documented in client record #5.
Client #6 was admitted on January 18, 2024 and discharged for successful program completion on February 26, 2024. A follow up was due to be completed by March 2, 2024. There was no follow up documented in client record #6.
Client #7 was admitted on January 30, 2024 and administratively discharged on February 26, 2024. A follow up was due to be completed by February 29, 2024. There was no follow up documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director reviewed with the newly appointed Admissions Director that the admissions department/intake tech will be responsible for follow-up information. Follow-up calls are to be completed within 5 days of discharge for completion, 3 days for unplanned discharges, and within 12 hours for AMA discharges. The admissions department will be responsible for contacting the client and the documentation of the encounter within the client record including information relative to the client's involvement with the project. The Admissions Director is responsible for ensuring all follow-up calls are completed according to ALAS policy and licensing regulations. ALAS QA will monitor for compliance in monthly chart audits. |