INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 6, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Alpine Springs Linsville LLC, DBA Alpine Springs Rehabilitation and 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of qualifications during an offsite inspection, Employee #2 was promoted to a counselor position in December 2019 but does not have the required one year of clinical experience to qualify for the position.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
That staff member was removed from the counselor position. Going forward the Compliance Officer will ensure that only staff meeting the requirements for counselor are hired (counselor will have BA degree or higher in an approved field and at least 1 year of clinical experience). HR representative will also verify the counselor qualifications prior to hire or promotion. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document monthly fire drills.
Documentation was reviewed during an offsite inspection. The facility was approved to provide services in July 2019. Fire drills were not documented for July 2019, August 2019, September 2019 and October 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance Officer or designated nurse conducts all fire drills for this building. Fire drills are scheduled monthly (but are unannounced) and will be documented on the revised (Jan. 2020) fire drill form. Compliance Officer will review forms monthly to ensure completion of the drill(s). |
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
The facility failed to document personnel on all shifts are trained to perform assigned tasks during emergencies. Documentation for ten staff was reviewed during an offsite inspection.
Employee #2 was promoted on December 16, 2019, and emergency training was documented as completed on April 27, 2020.
Employee #3 was hired December 4, 2018 and emergency training was documented as completed on March 10, 2020.
Employee #4 was hired on March 9, 2019 and emergency training was documented as completed on April 19, 2020.
Employee # 5 was hired on October 16, 2019 and emergency training was documented as completed on March 11, 2020.
Employee #6 was hired on October 16, 2019 and emergency training was documented as completed on March 10, 2020.
Employee #7 was hired on October 16, 2019 and emergency training was documented as completed on March 9, 2020.
Employee #8 was hired on December 4, 2018 and emergency training was documented as completed on March 10, 2020.
Employee #9 was hired on January 17, 2020 and emergency training was documented as completed on March 12, 2020.
Employee #10 was hired on February 25, 2020 and emergency training was documented as completed on March 10, 2020.
Employee #11 was hired on February 28, 2020 and emergency training was documented as completed on March 12, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR will train all new hires on the Disaster Emergency Plan (DEP-1) during new hire orientation. Staff will sign off that they received this training in Bamboo. Also, All staff will receive a refresher training on the Disaster Emergency Policy in March of each calendar year; and it will be documented in Bamboo. The Compliance Officer will monitor / coordinate with Human Resources and ensure that all staff are trained on Fire and Disaster plans / policy as noted above. |
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
Facility failed to maintain a written fire drill that included exit route used, evacuation time and smoke detector / fire alarm was operative.
Documentation was reviewed during an offsite inspection.
Fire drill logs do not document exit used for November 2019, December 2019, January 2020 and March 2020.
Evacuation time was not documented for November 2019. Evacuation of people from the facility was not documented for December 2019.
Documentation was missing that a smoke detector / fire alarm was activated for the drills conducted in November and December 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The missing fire drill items were identified by the DDAP inspector during the January 2020 inspection in the Linesville facility. Those items were corrected on the spot and were in place for all fire drills from Jan. 2020 forward. The Compliance Officer or designated nurse conduct all fire drills for this facility and will fill out the form completely; including: activating the alarm;exit route used; evacuation time; smoke detector operative etc. as noted on the DDAP approved form. The Compliance Officer will review the fire drill forms monthly to ensure All items are completed. Clients will be evacuated from the building as per the regulation. The facility has requested a waiver from the evacuation requirement. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Facility failed to conduct a fire drill during sleeping hours at least every 6 months.
Documentation was reviewed during an offsite inspection.
The facility was approved to provide services in July 2019, and a sleeping fire drill was due in January 2020 and was not completed until March 20, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance Officer will track when a 6 month sleeping hours drill is due for this facility. The night shift (11pm-7am) nurse is designated to complete the sleeping hours drill. Compliance officer will review the completed fire drill form for the sleeping hours drill to ensure it was conducted and filled out completely by the night shift nurse. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Facility failed to activate a fire alarm or smoke detector during each fire drill.
Documentation was reviewed during an offsite inspection.
Documentation was missing that a smoke detector / fire alarm was activated for the drills conducted in November and December 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The updated fire drill form (Jan. 2020) has a section to fill out that the alarm was activated. Staff will activate the alarm during all fire drills and document same. Compliance Officer will review all fire drill forms, and ensure that staff conducting the fire drill activate the alarm during all fire drills. |