INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in three out of three employee records reviewed.
Employee #1 was hired on December 12, 2022 as the project director and was still in the position as the date of the inspection. There was no documentation that the individual training plan was developed with input from both the employee and the supervisor.
Employee #2 was hired on December 12, 2022 as a facility director and was still in the position as of the date of the inspection. There was no documentation that the individual training plan was developed with input from both the employee and the supervisor.
Employee #3 was hired on January 11, 2021 as a clinical supervisor and was still in the position as of the date of the inspection. There was no documentation that the individual training plan was developed with input from both the employee and the supervisor.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Since the inspection date, the Facility Director worked with the Director of Human Resources and developed a form and process to address this deficiency. HR will initiate, track, and ensure compliance of the individual training plans with supervisors. All new staff will meet with their supervisors within 30 days of hire, complete the form and sign it, and return to HR to file and track.
In our HR system, we will put in dates when trainings are due, it sends a reminder to the employee, manager, and Director of HR when a training is due, completed, and past due. Once the training form is completed within their 30 days of hire or change of position, HR will enter all the training dates in each employees' files to track and ensure completion. Our training year will renew each year on July 1st. At this time, all staff's training plans will be reviewed to ensure trainings were completed according to the set plan, and new ones will be completed for the following training year. Same process will take place, HR will enter the trainings in the system to track and ensure completion of trainings on set dates in the training plans.
All new staff that were in the 30-day hire date range were given the new form and process completed on them. All professional staff who took new positions within 30 days were given the new form and process was completed. Employees and supervisors signed the individual training plans and copies are in their HR files. All new staff are given the plans at orientation. This was corrected effective on 2/1/2023.
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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on January 24, 2023, the facility failed to ensure cold food was at or below 40F.
The facility did not have a mechanism to ensure the temperature of cold food was at or below 40F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the inspection date, a thermometer was placed inside the deficient area making this deficiency in compliance. Per our policy, the thermometers are checked daily by staff, and monitored for compliance monthly through our monthly safety rounds checklist. Any non-compliance readings will be reported immediately.
Staff will be retrained on this policy at the February staff meeting.
The facility director monitors the compliance of the monthly safety round checklists. This deficiency was corrected on 1/25/23, but will be in full compliance effective 3/1/23 after all staff is retrained on the policy.
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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 the facility ' s unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of ambulance personnel.
The facility did not report unusual incidents that required ambulance personnel at the facility that occurred on September 3, 2022, October 6, 2022, October 7, 2022, October 9, 2022, October 18, 2022, October 22, 2022, October 27, 2022, and December 11, 2022.
These findings were reviewed with the facility staff during the licensing inspection process.
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Plan of Correction
Alpine Springs has an internal process in place for reporting and investigating unusual events.
Since the inspection date, we adapted our internal reporting system to have an area that marks if it is one of the following incident reports, then the facility director will be immediately notified by email, and report within 3 business days. The following events will be reported:
Physical or sexual assault by staff or a client.; Death or serious injury due to trauma, suicide, medication error or unusual circumstances.; Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.; Event at the facility requiring the presence of police, fire or ambulance personnel.; Outbreak of a contagious disease requiring CDC notification.
Effective 2/15/2023, all events of the above categories will be reported in the given timeframe of 3 days. The program director will be included on the email notifications as a backup for reporting the events.
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