INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 28, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Alpine Springs Linesville LLC dba Alpine Springs Rehabilitation was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of staff time sheets and the client census, the facility failed to have one primary care staff person available for every seven clients.
On 10/6/22, the client census was 11. There was only one primary care staff person on duty from 4pm-11pm.
On 10/13/22, the client census was 10. There was only one primary care staff person on duty from Noon - 11pm.
On 11/15/22, the client census was 10. There was only one primary care staff staff person on duty from 7am-11am and 3pm - 7pm.
On 12/7/22, the client census was 10. There was only one primary care staff person on duty from 3pm-11pm.
On 1/9/23, the client census was 8. There was only one primary care staff person on duty from 12am-6am and 11am--midnight.
On 2/10/23, the client census was 9. There was only one primary care staff person on duty from 7am-8am and 5pm-11pm.
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Plan of Correction
704.12 Full-time equivalent (FTE) maximum client/staff and
client/counselor ratios.
Since the visit, we dropped our maximum bed count to 7, until we could fulfill the FTE client/staff ratio to meet regulations consistent effective on 3/1/23. We have switched shifts around to meeting the necessary requirements, hired five new professional staff this year who are now trained, and have 4 open positions in the process of filling. We will limit our beds to 7, anytime we have a staffing decrease or issue. Our beds are currently limited to 7, with plans to open back to 14 on 3/20/2023, when we can meet the client/staff FTE requirements.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on February 28, 2023, the facility failed to store all food items off the floor. A storage container filled with popcorn and a box of potato chips were observed on the floor of the pantry. In addition, cases of Gatorade were observed on the floor in the hallway.
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Plan of Correction
705.7 Food service
As soon as this was brought to our attention, food items were picked up off the floor and placed on the appropriate shelving, both in the hallway and in the food storage pantry. Staff was reminded of the regulation and everything was fixed and in compliance that day. Since the visit, two policies were updated to address the regulation 705.7 (b) (6) store all food items off the floor; Physical Environment Policy EC-06 and Dietary Policy D1-01. All staff will be retrained on the updated policies and procedures via an email and signing off on both updated policies by 3/30/23. This was also added to our monthly safety rounds checklist, which is completed each month by the facility managers to ensure compliance. The Director of Operations will monitor compliance of the monthly checklist. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the facility's current license, their client census and other administrative documentation, the facility failed to notify the Department of a change in their authorized maximum capacity.
The facility is licensed for seven beds in their detoxification services and seven beds in their inpatient rehabilitation treatment services. The facility exceeded their allowable capacity in the detoxification activity on the following dates:
On 10/6/22, the detoxification activity census was 11 clients.
On 10/13/22, the detoxification activity census was 10 clients.
On 10/24/22, the detoxification activity census was 12 clients.
On 11/2/22, the detoxification activity census was 8 clients
On 11/10/22, the detoxification activity census was 8 clients
On 12/7/22, the detoxification activity census was 10 clients
On 12/29/22, the detoxification activity census was 8 clients
On 1/9/22, the detoxification activity census was 8 clients
On 2/10/23, the detoxification activity census was 9 clients
On 2/24/23, the detoxification activity census was 8 clients
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Plan of Correction
709.14 Restriction on license.
Our previous Program Director was responsible for submitting a request to flex beds which was done in previous years. Administration was informed this was completed and the program director misled us to believe we were complying. The previous program director is no longer with the company. As soon as we found out we were not in compliance, we adjusted the bed limit to meet the current license, and applied for a request to flex beds again. As of 3/14/23, we were approved to flex the beds at the facility until 2024, in which we will reapply each year and comply with the license requirements.
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