INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2023 through October 18, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on an administrative review, the project director failed to document and complete an annual evaluation of the overall training plan for the facility's prior training year. The facility's policy stated that the annual evaluation of the overall training and development will be completed by the director within 60 days of the end of the training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Annual Evaluation of Training Plan was completed by the Executive Director on the above listed date for all program personnel. This plan included policies and procedures, persons responsible and time-frames for completion. |
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 personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, with input from the employee and the supervisor, documented in one of seven personnel records reviewed.
Employee #5 was hired as a counselor on July 21, 2022. The last individual training plan was completed on July 21, 2022. There was no current training plan, in the personnel record, at the time of inspection.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An individual training plan was developed by the Executive Director with input from Employee #5 on 10/24/23.
At the start of each new training year, the Executive Director will meet with the employee(s) and collectively identify the hew training areas to be accomplished. Those that require outside trainings will then be forwarded to the Administrative Program Manager who will seek out the needed trainings and provide the information to the employee(s) and Executive Director.
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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 ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of four applicable personnel records reviewed.
Employee #5 was hired as a counselor on July 21, 2022 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than July 21, 2023; however, there was no documentation of completion of HIV/AIDS or TB/STD trainings at the time of inspection.
Employee #7 was hired as the Lead Monitor on April 7, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than April 7, 2023; however, the personnel record documented 1.75 hours of HIV/AIDS training.
This is a repeat citation from the October 1, 2021 and October 6, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Program Coordinator will check weekly for postings by DDAP Training Department and BHTEN, for HIV/AIDS, for 6 hours and TB/STD trainings for 4 hours. Once posted both employee #5 and employee #7 have been notified to complete the trainings they are deficient in as as soon as they are made available. Employee # 7 will only require HIV/AIDS. Employee #5 will require both trainings.
Both employees were notified of these requirements by the Executive Director in memos, in which it specifies they must be completed at soon as notified they are available. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure a project director and facility director completed at least 12 clock hours of training annually during the facility's October 1, 2022 through September 30, 2023 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the Project Director on December 15, 2021. The personnel record documented 0 hours of annual training for the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director/Program Director will complete 12 hours of required trainings, chosen from those specified, by 09/30/2024. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's October 1, 2022 through September 30, 2023 training year in three of three applicable personnel records reviewed.
Employee #2 was hired as a counselor on March 1, 1999. The personnel record documented 0 hours of annual training for the reviewed training year.
Employee #4 was hired as a counselor on May 9, 2022. The personnel record documented 0 hours of annual training for the reviewed training year.
Employee #5 was hired as a counselor on July 21, 2022. The personnel record documented 0 hours of annual training for the reviewed training year.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director/Program Director will complete 12 hours of required trainings, chosen from those specified, by 09/30/2024.
At the beginning of the training year, the Executive Director will notify the Board Chair and set a meeting to review the training plan together. Once approved, the Administrative Program Manager will seek out those desired trainings. This information will be provided to the Board Chair and the Executive Director.
With regard to the counseling staff, existing counselors will be notified by the Administrative Director of this requirement. This will be reviewed and monitored with them in each monthly meeting between the counseling staff, the Executive Director, and Administrative Program Manager to ensure completion.
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection, the facility failed to ensure that each bedroom had a bed with a solid foundation and a fire-retardant mattress in good repair.
The 2nd floor bedroom, located in building #438, had a mattress covering that was ripped.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The torn mattress covering was replaced by the ACA Maintenance staff with a new covering on 10/17/23.
While reoccurrences cannot be prohibited, the Maintenance Staff have been instructed to include inspection and immediate replacement of any torn, or otherwise damaged mattress covers, on their weekly reviews, This will be overseen by the Administrative Program Manager. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
The 3rd floor bathroom, located in building #440, had a combination shower/tub that did not have a slip-resistant surface.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The 3rd floor bathroom, located in building #440, had a combination shower/tub which was fitted with new a slip-resistant material.
Inspection of these areas for slip-resistance on a weekly basis, and results of inspections are reported to the Administrative Program Manager. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The 1st floor bathroom, located in building #438, had a faucet that was loose from the sink base.
The 2nd floor bathroom, located in building #440, had a combination shower/tub with what appeared to be mold/mildew on the top of the tub.
The 3rd floor bathroom, located in building #440, had a combination shower/tub with peeling or cracking paint, chipped caulking, rust, and what appeared to be mold/mildew.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following corrections were made by ACA Maintenance Staff: Building #438, tightened loose faucet at sink base.
The 2nd floor bathroom in building #440 was cleaned and sanitized.
The 3rd floor bathroom in Building #440 with a combination shower/tub, was corrected with removal of old caulking, rust removal, sanitization, and replaced with new caulking and paint on 10/17/23.
ACA Maintenance Staff will inspect each of the client apartments on a weekly basis, and report any needed repairs or improvements to the Administrative Program Manager. Any corrections needed will then be carried-out by ACA Maintenance Staff. |
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, the facility failed to keep food cold food at or below 40 hot food at or above 140 and frozen food at or below 0
The basement bedroom, located in building #438, had a refrigerator that registered a temperature of 50 and a freezer that registered a temperature of 10 at the time of the inspection.
The 2nd floor bedroom, located in building #438, had a freezer that registered a temperature of 12 at the time of the inspection.
The 3rd floor bedroom, located in building #440, had a freezer that registered a temperature of 10 at the time of the inspection.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following corrections were made by ACA Maintenance Staff:
Replacement of faulty thermometers inn the refrigerators located in building #438 2nd floor, basement bedroom in building #438,
and the 3rd floor bedroom located in building #440.
The Administrative Program Manager will ensure that the Maintenance Staff checks the status of the thermometers on a weekly basis, and that any malfunctions will be corrected immediately. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed.
There were space heaters located in the back counselor's office in building #440 and in the project director's office in building #438.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Two Space heaters which were present. One heater which was present in Building #338 and one in Building #440 were removed by ACA Maintenance Staff on 10/17/23.
A memo was sent to all staff, including maintenance, that space heaters are not to be used on the premises. All space heaters have been removed from ACA by the maintenance staff. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers at the facility were inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection tag of all the fire extinguishers in the facility was July of 2022.
These findings were with facility staff as part of the inspection process.
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Plan of Correction
All fire extinguisher were Inspected and replaced where needed by Tilley Inc. and pictures submitted to DDAP. The provision of this service was managed by the Administrative Program Manager, and completed on 11/01/23. The new extinguishers are valid through November,2024.
The Administrative Program Manager, had notified the ACA Management Company several months before. Unfortunately, financial delays prohibited corrective action from being taken until recently. The current extinguisher approvals are valid through November 2024.
The Executive Director and Program Manager will begin notifying the Management Company of this date 3 months prior to the extinguishers expiration, which will be past the date of next years Licensing inspection. |
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
Based on review of the facility's November 2022 through September 2023 fire drill logs, the facility failed to conduct unannounced fire drills during the months of November 2022 and December 2022.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Subsequently, all required fire drills have been conducted and dates set for them to be performed each month going forward.
This activity is carried-out by ACA Maintenance Staff and overseen by the Administrative Program Manager. The monthly completion of Fire Drills and other tasks falling under the Administrative Program Manager will be reviewed each month in the supervision meeting of the Program Manager and the Executive Director. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility, which is publicly funded, failed to complete, and make available to the public an annual report, which is to include a statement disclosing the names of officers, directors, and principal shareholders.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A notice of the availability of the Alternative Counseling Associate Annual Report was published through the The Pottstown Mercury Paper to the Philadelphia Media Area on 12/06/23.
This activity was performed by the Administrative Program Manager.
The ACA Executive Director, in his capacity notified the Board Chair and the Management Company for ACA for several months prior, to obtain the needed reports. In an attempt to ensure that this action is not repeated, a Certified Letter from the ACA Executive Director to the Board Chair and ACA Comptroller beginning 3 months prior to its' being required to document the facilities efforts. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project director failed to prepare, annually update, and sign the written manual delineating the project's policies and procedures for the current year. The last date the manual was signed by the project director was June 29, 2021.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director prepared, updated, and signed the Program's Policies and Procedures Manuel on 12/12/23.prviding the
An ACA Policy and Procedure Manual review has been placed on the calendar for the month prior to Licensing Inspection, 09/2024. At the time of that review all necessary components of updating the manual and providing the required signature will occur.
The Administrative Program Manager will alert the Executive Director when the Policy Manual review is to begin. The Executive Director is responsible for carrying-out the required review once notified. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in one of two applicable client records reviewed.
The facility's policy and procedure manual stated that the emergency contact will be notified within 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client #6 was admitted on December 14, 2022 and was discharged against medical advice on February 10, 2023. The emergency contact was notified of the client leaving against medical advice on February 13, 2023 at 6:57AM.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The ACA Policy 7.A addressing Emergency Contact for clients, has been amended to read that the ACA Counselor will attempt to make live contact, in the process of notification, within 12 hours of client's discharge. Attempt to make live contact will continue for 72 hours.
The Executive Director and Administrative Program Manager will ensure that the corrective plan of action is implemented. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This is a repeat citation from the October 6, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The management group servicing ACA obtained the services of Harrell Stine, and Associates, LLC., Tampa, Fla., an independent certified public accountant for the provision of fiscal auditing services required. Report received,11/11/23.
Fiscal and external auditing services are acquired by the Management Group for ACA, who is contacted by the ACA Executive Director through the Board Chair and Comptroller. While the implementation of such services are the responsibility of the Executive Director, the acquisition of them are upon the Board Chair and Comptroller.
Notification to them was made several time months prior to its being required.
The Executive Director will take steps to further underscore the importance and need for the completion of this service provision by sending a Certified letter to the Board Chair and the ACA Comptroller along with the stated requirement for the need of this service provision, each month, if needed for 3 months prior to it's being required.
This information including the licensing requirement was sent during this inspection period but will now be sent by certified mail with a return receipt requested to aid in underscoring the importance of this being completed in a timely manner, as the Board Chair and Comptroller reside in Tampa Florida.
In addition to this action the Executive Director will continue to notify the Board Chair 3 months prior during their in-person meetings and furnish him with a copy of the Certified Letter sent. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the facility's policy and procedure manual, the governing body failed to include a policy and procedure for the utilization of volunteers within their personnel management policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Alternative Counseling Associates, Inc. does not utilize volunteer, given the highly confidential nature of the work performed. Therefore, a policy has been written to further underscore this fact under, Utilization of Volunteer Services, dated 12/10/2023 |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on a review of the facility's policy and procedure manual, the governing body failed to include a policy and procedure for the supervision of staff within their personnel management policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Supervision of client related service by Monitors and Counselors at ACA, occurs in the following manner and is now stated in the Policy titles Supervision of Client Related Staff. Staff Monitors, who assist id daily patient activities have a Lead Monitor who is supervised by the Administrative Program Manager. This meeting occurs weekly. All Monitoring Staff are Supervised in a Group meeting monthly by the Administrative Program Manager.
Counseling Staff are supervised monthly by the Executive Director in a group setting with individualized supervision occurring on an as-needed basis for immediate concerns, or identified patient matters requiring attention. |
709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
Based on a review of the facility's policy and procedure manual, the governing body failed to include a policy and procedure for the orientation of new employees within their personnel management policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Alternative Counseling Associates, maintains a general and specific orientation plans and schedules, including training needs for Client Monitors and Counselors. These procedures will be formulated into a formal Policy, including the Procedures and requirements and timelines. This action will be taken by the Executive Director with input form the Administrative Program Manager, who directly supervises the Monitoring Staff.
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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 a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #4 was admitted on March 15, 2023 and was discharged on April 11, 2023. There was documentation of disclosures to a urinalysis laboratory on April 7, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A specific consent form for the purpose of obtaining client urinalysis services was created to be signed by the individual for whom the test would be analyzed. The form was created on11/13/23 by the Administrative Program Manager and reviewed by the Executive Director for immediate implementation.
The Administrative Program Manager will make the specific urinalysis consent available to counselors upon request or if needed by Monitors. The Executive Director, will be responsible for the implementation and follow-through of this activity. |
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 document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of seven client records reviewed.
Client #2 was admitted on July 27, 2023 and was active at the time of inspection. There were two blank release of information forms that were signed and dated by the client on July 27, 2023; however, the name of the person, agency, or organization to whom the disclosure was to be made to was not documented on either form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A memo will be sent to all ACA Counseling Staff from the Executive Director stating that blank consent forms are not permitted in the client chart and must be utilized on an as needed basis.
Blank chart assembly falls under the direction of the Administrative Program Manager who will review each chart prior to its being utilized to assure that no blank consent forms are present at the charts initial utilization. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.
Client #7 was admitted on April 20, 2023 and was discharged on July 20, 2023. There was a release of information form to a recovery house that was signed and dated by the client on June 26, 2023; however, there was no documentation that indicated a copy of the consent form was offered to the client.
This is a repeat citation from the October 1, 2021 and October 6, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A memo will be sent by the Executive Director to all counselors underscoring the necessity to offer, and document that the client was offered a consent form when utilized. ACA Consent Forms will have the area stating the client was offered the consent for and area for it to be noted highlighted to enhance the counselor attention to this requirement.
In addition to these actions, a list of all areas requiring improvement of counselor documentation will be reviewed in the monthly meeting held with the Executive Director, counselors and Administrative Program Manager. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of a physical assault or sexual assault by staff or a client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will include a new topic heading chapter in the ACA Policy and Procedure Manual entitled, Unusual Incidents. Within this chapter, the guidelines presently followed by employees within the facilities as "procedures" will be incorporated as policies and procedures within the ACA Policy and Procedure Manual. Included within this chapter will be the implemented policies and procedures in the event of the following: Theft, burglary, break-in, fire, or structural damage to the facility. This chapter shall also include policies and procedures utilized responding to unusual events at the facility requiring the presence of police, fire or ambulance personnel.
Policies and Procedures for the potential outbreak of a contagious disease, as defined by the Center for Disease Control, will also be included.
Under separate topic heading within this chapter Policies and Procedures to be followed in the event of physical assault by or to staff or clients will be outlined, and time-frames for reporting and to which agencies will be included.
Incorporated within the topics mentioned will be the requirements for reporting to the necessary agencies and Licensing Body, and the time-frames for doing so; such as, reporting the presence of the police, fire of ambulance to DDAP within 3 days. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of the selling or use of illicit drugs on the premises.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the ACA Code of Ethics Policy, it state that the use of illicit drugs along with the other policy components will result in termination. Added to that existing Policy #3B, has been wording stating that selling, or distributing of illicit drugs, by staff or clients will result in termination or client discharge.. Policy amended on 12/12/23. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will include a new topic heading chapter in the ACA Policy and Procedure Manual entitled, Unusual Incidents. Within this chapter, the guidelines presently followed by employees within the facilities as "procedures" will be incorporated as policies and procedures within the ACA Policy and Procedure Manual. Included within this chapter will be the implemented policies and procedures in the event of the following: Theft, burglary, break-in, fire, or structural damage to the facility. This chapter shall also include policies and procedures utilized responding to unusual events at the facility requiring the presence of police, fire or ambulance personnel.
Policies and Procedures for the potential outbreak of a contagious disease, as defined by the Center for Disease Control, will also be included.
Under separate topic heading within this chapter Policies and Procedures to be followed in the event of physical assault by or to staff or clients will be outlined, and time-frames for reporting and to which agencies will be included.
A separate topic heading within the Unusual Incidents Chapter will include
policies and procedures to respond to the unusual incident of a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment.
Incorporated within the topics mentioned will be the requirements for reporting to the necessary agencies and Licensing Body, and the time-frames for doing so; such as, reporting the presence of the police, fire of ambulance to DDAP within 3 days. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of a significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
While not listed as a Procedure for "Unusual Incidents" but under the ACA Policy Heading: Disaster Plan/Risk Management, a comprehensive and detailed plan does exist as to all actions and activities to be taken in the course of
the disasters mentioned, and more.
This Policy and it's procedures total 9 pages and are beyond the scope of submission here.
This Policy will be copied and included under a new Policy and Procedure Heading for "Unusual Incidents." |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of a theft, burglary, break-in or similar incident at the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will include a new topic heading chapter in the ACA Policy and Procedure Manual entitled, Unusual Incidents. Within this chapter, the guidelines presently followed by employees within the facilities as "procedures" will be incorporated as policies and procedures within the ACA Policy and Procedure Manual. Included within this chapter will be the implemented policies and procedures in the event of the following: Theft, burglary, break-in, fire, or structural damage to the facility. This chapter shall also include policies and procedures utilized responding to unusual events at the facility requiring the presence of police, fire or ambulance personnel.
Policies and Procedures for the potential outbreak of a contagious disease, as defined by the Center for Disease Control, will also be included.
Incorporated within the topics mentioned will be the requirements for reporting to the necessary agencies and Licensing Body, and the time-frames for doing so; such as, reporting the presence of the police, fire of ambulance to DDAP within 3 days.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of an event at the facility requiring the presence of police, fire or ambulance personnel.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will include a new topic heading chapter in the ACA Policy and Procedure Manual entitled, Unusual Incidents. Within this chapter, the guidelines presently followed by employees within the facilities as "procedures" will be incorporated as policies and procedures within the ACA Policy and Procedure Manual. Included within this chapter will be the implemented policies and procedures in the event of the following: Theft, burglary, break-in, fire, or structural damage to the facility. This chapter shall also include policies and procedures utilized responding to unusual events at the facility requiring the presence of police, fire or ambulance personnel.
Policies and Procedures for the potential outbreak of a contagious disease, as defined by the Center for Disease Control, will also be included.
Incorporated within the topics mentioned will be the requirements for reporting to the necessary agencies and Licensing Body, and the time-frames for doing so; such as, reporting the presence of the police, fire of ambulance to DDAP within 3 days. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of a fire or structural damage to the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will include a new topic heading chapter in the ACA Policy and Procedure Manual entitled, Unusual Incidents. Within this chapter, the guidelines presently followed by employees within the facilities as "procedures" will be incorporated as policies and procedures within the ACA Policy and Procedure Manual. Included within this chapter will be the implemented policies and procedures in the event of the following: Theft, burglary, break-in, fire, or structural damage to the facility. This chapter shall also include policies and procedures utilized responding to unusual events at the facility requiring the presence of police, fire or ambulance personnel.
Policies and Procedures for the potential outbreak of a contagious disease, as defined by the Center for Disease Control, will also be included.
Incorporated within the topics mentioned will be the requirements for reporting to the necessary agencies and Licensing Body, and the time-frames for doing so; such as, reporting the presence of the police, fire of ambulance to DDAP within 3 days. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to develop and implement policies and procedures to respond to the unusual incident of an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will include a new topic heading chapter in the ACA Policy and Procedure Manual entitled, Unusual Incidents. Within this chapter, the guidelines presently followed by employees within the facilities as "procedures" will be incorporated as policies and procedures within the ACA Policy and Procedure Manual. Included within this chapter will be the implemented policies and procedures in the event of the following: Theft, burglary, break-in, fire, or structural damage to the facility. This chapter shall also include policies and procedures utilized responding to unusual events at the facility requiring the presence of police, fire or ambulance personnel.
Policies and Procedures for the potential outbreak of a contagious disease, as defined by the Center for Disease Control, will also be included.
Incorporated within the topics mentioned will be the requirements for reporting to the necessary agencies and Licensing Body, and the time-frames for doing so; such as, reporting the presence of the police, fire of ambulance to DDAP within 3 days.
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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 discussion with facility staff, the facility failed to notify the Department within 3 business days of an event at the facility which required the presence of police, fire, or ambulance personnel.
It was reported, during discussions, that on June 30, 2023, the fire department was called to the facility. The facility was to report this incident to the Department no later than July 5, 2023; however, the incident was not reported as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will include a new topic heading chapter in the ACA Policy and Procedure Manual entitled, Unusual Incidents. Within this chapter, the guidelines presently followed by employees within the facilities as "procedures" will be incorporated as policies and procedures within the ACA Policy and Procedure Manual. Included within this chapter will be the implemented policies and procedures in the event of the following: Theft, burglary, break-in, fire, or structural damage to the facility. This chapter shall also include policies and procedures utilized responding to unusual events at the facility requiring the presence of police, fire or ambulance personnel.
Policies and Procedures for the potential outbreak of a contagious disease, as defined by the Center for Disease Control, will also be included.
Incorporated within the topics mentioned will be the requirements for reporting to the necessary agencies and Licensing Body, and the time-frames for doing so; such as, reporting the presence of the police, fire of ambulance to DDAP within 3 days.
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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, the facility failed to develop and document, with the client, an individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #2 was admitted July 27, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan, in the record, was not dated and had pre-established goals and problems; therefore, the treatment plan was not individualized or developed with the input of the client.
Client #3 was admitted on August 15, 2023 and was discharged on September 7, 2023. The individual treatment and rehabilitation plan, in the record, was not dated and had pre-established goals and problems; therefore, the treatment plan was not individualized or developed with the input of the client.
Client #7 was admitted on April 20, 2023 and was discharged on July 20, 2023. There was no individual treatment and rehabilitation plan, in the record, at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The tasks and responsibilities for counselors are stated in their Job description and reviewed during their training and orientation period. A memo will be sent to all counselors addressing their specific responsibilities underscoring the deficiencies stated herein. In addition, a checklist with all the required documentation areas will be created for counselors with the time-frames for each included.
To further assure that these responsibilities are implemented, a review of each new client's chart will be made on a weekly basis by the Administrative Program Manager and reviewed by the Executive Director.
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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, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every thirty days in one of three applicable client records reviewed.
Client #1 was admitted on July 25, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on July 28, 2023, and the first update was due no later than September 28, 2023; however, the update was not completed at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The tasks and responsibilities of counselors are outlined in their job description and reviewed during the initial training period. To further assure all the tasks and responsibilities are carried-out in a timely and accurate manner, a checklist will be made for counselors to utilize which will include the time-frames for completion.
Charts will be reviewed weekly by the Administrative Program Manager, with deficiencies brought to the attention of the Executive Director.
To further facilitate the accomplishment of the newly developed chart review tasks as Lead Counselor will be utilized with these tasks added to their responsibilities.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one applicable client records reviewed.
Client #7 was admitted April 20, 2023 and was discharged on July 20, 2023. There was no documentation of an aftercare plan, in the record, at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The tasks and responsibilities of counselors are outlined in their job description and reviewed during the initial training period. To further assure all the tasks and responsibilities are carried-out in a timely and accurate manner, a checklist will be made for counselors to utilize which will include the time-frames for completion.
Charts will be reviewed weekly by the Administrative Program Manager, with deficiencies brought to the attention of the Executive Director.
To further facilitate the accomplishment of the newly developed chart review tasks a Lead Counselor will be utilized with these tasks added to their responsibilities. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction ensuring a copy of a consent form was offered to the client was submitted and approved by the Department for the October 1, 2021 and October 6, 2022, annual licensing inspections. Failing to ensure a copy of a consent form was offered to the client was again found to be a deficiency in the October 17, 2023 through October 18, 2023, licensing inspection.
A plan of correction ensuring all facility staff receives the mandatory communicable disease trainings within the regulatory timeframe was submitted and approved by the Department for the October 1, 2021 and October 6, 2022, annual licensing inspections. Failing to ensure all staff received the mandatory communicable disease trainings within the regulatory timeframe was again found to be a deficiency in the October 17, 2023 through October 18, 2023, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A memo will be sent by the Executive Director to all counselors underscoring the necessity to offer, and document that the client was offered a consent form when utilized. ACA Consent Forms will have the area stating the client was offered the consent for and area for it to be noted highlighted to enhance the counselor attention to this requirement.
In addition to these actions, a list of all areas requiring improvement of counselor documentation will be reviewed in the monthly meeting held with the Executive Director, counselors and Administrative Program Manager.
In order to assist in the adherence to the newly implemented required changes to assure adherence to the stated corrections needed, the addition of a Lead Counselor position will be initiated to assist with overseeing counselor compliance, and report deficiencies to the Executive Director to address those areas with the specific counselor(s).
The Administrative Program Coordinator will check weekly for postings by DDAP and BHTEN for the HIV/Aids,(6hrs), and the TB/STD Trainings (4 hours) for staff requiring these mandatory trainings within the first year. These training required time-frames will be mentioned in the monthly counselor meetings. Those counselors needing the needed training will be informed prior to the deadline in a written form that they must complete them as a requirement too retain their position at ACA.
The memo will be sent by the Executive Director and follow-up prior to the training date(s) made by the Administrative Program Manager and/or Lead Counselor.
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