INITIAL COMMENTS
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This report is a result of a plan of correction follow-up inspection conducted on March 25, 2024 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(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 three of six applicable personnel records reviewed.
Employee #1 was hired as the project director on December 15, 2021. The HIV/AIDS training and the TB/STD training were due no later than December 15, 2023; however, there was no documentation of the completion of both the HIV/AIDS and TB/STD trainings at the time of the inspection.
Employee #5 was hired as a counselor on July 21, 2022. The HIV/AIDS training and the TB/STD training were due no later than July 21, 2023; however, there was no documentation of the completion of the HIV/AIDS and TB/STD trainings at the time of the inspection.
Employee #7 was hired as the Lead Monitor on April 7, 2021. The HIV/AIDS training was due no later than April 7, 2023; however, there was documentation of the employee only receiving 1.75 hours of HIV/AIDS training at the time of the inspection.
This is a repeat citation from the October 1, 2021, October 6, 2022, and October 17, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1, had completed the required trainings at a previous employment in 2020, as VP of Clinical Programs, but did not receive the certificates Attempts to acquire them were not successful, and finding suitable approved trainings were difficult during, and immediately post-Covid-19.
Approved trainings are now available through Relias Academy and will be completed by this employee on or before 5/09/2024
Employee #5.This counselor had taken the needed courses while in her Master's Program but could not locate the certificates prior to the site-inspection. The required trainings have been completed through Relias Academy on
5/02/2024.
Employee #7, This Monitor had mistakenly taken a 1 hour HIV training instead of the 4 hours required training. She has completed the necessary training(s) on 5/01/2024 through Relias Academy.
The Director and administrative Program Coordinator with assistance of the Lead Monitor will direct, implement and monitor that the following process is enacted and followed-through.
The Director will send a memo referencing the Policy that required trainings are completed within the allotted time-frame and the new process to be followed. This will include, forms made available for each employee needing trainings to fill-out once a training has been completed. Each form will list where trainings can be accesses, the training tile, hours provided/completed and date completed. Each completed form will be given to the Administrative Program Manager along with a copy of the completion notification/certificate.
This process will be reviewed in the next counselor and Monitor meetings.
This topic will be revisited in each of these meetings 3 months prior to the final date required. Those staff, not having any of the needed trainings will be required to complete them on assigned work day and submit the form and completion certificate information to the Program Coordination for filing.
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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 safe and free from any danger to the safety and well-being of clients, employees, and visitors.
There was an exposed, uncovered electrical outlet located in the counselor's office in building #440.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Subsequent to the last site-visit, an electrical outlet without a cover was noted underneath a counselor's office, in 440 E. High St. Pottstown, Pa. This was remedied immediately after the visit.
Going forward the maintenance department has note the locations of all within ACA.
These will be routinely review and and deficiencies corrected. |
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 is a repeat citation from the October 17, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately after the last site-visit, slip-resistant strips were placed in the bathroom shower/tub located at 440 E. High St Pottstown, Pa.
This replaced once prior and was to the second visit.
Subsequently, the Lead Monitor, will utilize a checklist to review all apartments for any needed repairs or deficiencies. |
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 2nd floor bathroom, located in building #438, had a combination shower/tub with what appeared to be rust along the tub floor. Also, the tub faucet was leaking water. Additionally, there was a metal air vent, above the toilet, that was loose and hanging by one screw.
The 2nd floor bathroom, located in building #440, had a combination shower/tub with what appeared to be mold and mildew on the top of the tub. Also, the sink faucet was leaking water. Additionally, this bathroom was currently under construction due to a bathroom leak from the 3rd floor bathroom directly above. According to the facility's manager, the leak occurred approximately three weeks prior to the inspection; however, this apartment was still currently occupied by clients during the renovation process.
The 3rd floor bathroom, located in building #440, had a combination shower/tub with what appeared to be peeling or cracking paint, chipped caulking, rust, and mold and/or mildew. Also, the tub faucet was leaking water. Additionally, this bathroom was currently under construction due to a leak from the toilet. The floor tile was cracked and bows in. According to the facility's manager, the leak occurred approximately three weeks prior to this inspection; however, this apartment was still currently occupied by clients during the renovation process.
This is a repeat citation from the October 6, 2022 and October 17, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Remediation of mold, mildew and rust-like stains were made after the first visit. The leaking faucets were addressed and reoccurred.
These issues, upon review by the Director, Administrative Program Coordinator and Maintenance staff, were then deemed to require more extensive repairs then those which had been made initially and prior in an older facility the age of ACA, having the type of utilization it endures.
Such repairs have been underway, and have included removal of all previous caulk and other substances used previously. The repairs have included replacement of parts etc. where necessary.
Completion of repairs to these areas was concluded within the past week.
A checklist of prior areas of concern and review of all apartments is now to be conducted weekly by the Monitoring Staff. In addition, a monthly review of the client apartments and facility in-general will be conducted by the Director, Program Manager and Maintenance staff. |
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 was a space heater located in the back counselor's office of building #440.
This is a repeat citation from the October 17, 2023, annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Removal of all ACA purchased space heaters were removed after this
year's first site-visit and a memo sent addressing this matter to all staff.
With limited office space at ACA, all offices including that of the Director are sometimes utilized by other staff. The heater referred to in this observation was not an ACA purchased heater an not approved for use.
This issue was addressed again with the staff member involved after this was noted in the follow-up visit.
A Note-to-File, was placed in the employee's file, after a meeting was held with the employee and the Director, notifying tis person that this could not occur again and could result in actions including termination.
No space heaters had been seen by the Director or Administrative Program Manager prior to the date of the noted incident, on routine rounds of the facility. |
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 and October 17, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The necessity for the Annual Report will be sent to the Board Chair and Comptroller, in order that steps be taken to fulfill this requirement.
The ACA Executive Director will meet in-person with the Board Chair, who is responsible for facilitating Corporate financial requests and documentation. Subsequently, the ACA Executive Director will also verify with accountant responsible for the report process that Annual Report will be finished as required.
The Executive Director will contact the Board Chair and Comptroller on a monthly basis via email, and discussed during the Board Chair in-person visits to ACA, to monitor the progress for the Annual Report Completion.
It will be conveyed to the Comptroller to have the Annual report completed one month prior to the date stated as final, as shown above.
Once the Annual Report is submitted to ACA, it will be published in a local paper to be made available to the public as required.
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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 the written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact would be notified no later than 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 February 20, 2024 and was discharged against medical advice on March 4, 2024. There was no documentation that the emergency contact was notified of the client's discharge from the facility against medical advice as of the date of the inspection.
This is a repeat citation from the October 6, 2022 and October 17, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the initial site-visit, A memo was sent to all clinical and monitoring staff underscoring the need to follow the ACA Policy for notifying emergency contacts when needed. This was further reiterated in recent counselor and Monitor meetings held on 4/18/2024, and 4/29/2024.
After the initial finding of a late/no contact, An ACA Counselor devised and utilized a separate communication sheet for the chart to remind and record such contacts. This form has now been required for all counselors. Monitoring staff, are to record such occurrences in their communication log.
We have now created a separate binder for this form for Monitors as well.
The instance of the current citation was investigated by the Director. The staff person in-question, stated that the call was made but he had failed to document it. This staff person was a relatively new hire and perhaps not aware of the requirement or forgot.
Utilizing the separate binder along with on-going reminders in monthly meetings should aid in correcting this failure of action and documentation.
These steps will be implemented by the Administrative Program Manager and followed-up by the Lead Monitor. On-going compliance with the process will be reported to the Director.
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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 the completion of 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, for fiscla years ending June 2022 and June 2023.
This is a repeat citation from the October 6, 2022 and October 17, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will monitor the progress of the new audit/fiscal plan information with the Board Chair on a monthly basis and the publication will be enacted by the Administrative Program Manager.
In addition to the above the following plan will be enacted:
The Director will send the Board Chair and comptroller, a copy of the DDAP requirements and any prior deficiencies, including the date that is being set-forth to have the fiscal requirements fulfilled.
The Director will be directly in communication with the independent auditor or their designee, to monitor the actual progress of the financial requirements, and let them know when it must be finalized and sent to ACA.
To further ensure that completion is timely, The Executive
Director of ACA will let the Auditor know the information must be completed and sent to ACA at least one month prior to the next DDAP inspection date to further ensure accuracy of information requested and timeliness.
Monthly contact with the auditor will be performed by the Director and/or Administrative Program Manager to ensure progress is being made toward the ACA financials completion.
Continued discussions between the ACA Executive Director, The Board Chair and Comptroller, will be made after each contact with the Auditor, especially if added intervention is required to ensure the timely completion of the financials required. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed secure hard copy client records within locked storage containers.
There were several client documents throughout the counselor's office located in building #438. Additionally, there were client documents, located in unsecure boxes, on two separate desks and also on shelves.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselor's office referred to in the citation also contains file cabinets which lock for the purpose of securing them.
Over the past 3 months this counselor, who is very experienced in the Drug and Alcohol field accepted partial responsibility of two other counselors, for purposes of illness. In doing-so, he also worked late into the evenings doing groups, and had moved from part-time to full-time work
This individual, is aware of the necessity of having files placed in locked containers.
However, it is understood that these regulations must be carried-out regardless of workload. Toward this end, the Director met with this counselor to address this matter and a note was placed in his file addressing this occurrence.
To further assure that this does not occur with any counselor's files, the evening Monitor(s) will inspect each counselors office and secure any client files not already placed in a locked container. |
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 the disclosure is made to on a consent to release information form in one of thirteen client records reviewed.
Client # 1 was admitted on December 7, 2024 and was discharged on February 24, 2024. There were two blank release of information forms signed by the client on December 7, 2024 and both release forms did not include the name of a person, agency, or organization to whom the disclosure would be made to.
This is a repeat citation from the October 17, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Subsequent to the initial finding of blank confidentiality forms present in a selection of client charts, The Director conducted a broad inspection of then recent and current client charts, with instructions that any incomplete release of information forms, or those with a client signature and otherwise incomplete be removed from client charts. This was conducted ,by counseling staff and the Administrative Program Manager. However, upon recent inspection, one file was found containing such a charts
New counseling charts are assembled by Monitors, and have been instructed not to include the blank release of information forms at all, in newly assembled charts.
Client requests, or need for a release of information form will be completed in their entirety, and then signed at the time the service is being requested or needed in the presence of a counselor or Adminsitrative ProgramManager. |
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 document the specific information to be disclosed on consent to release information forms in ten of thirteen client records reviewed.
Client # 2 was admitted on March 4, 2024 and was still active at the time of the inspection. The release of information forms to the pharmacy and the laboratory were signed by the client on March 4, 2024, but both release forms did not include the specific information to be disclosed.
Client # 3 was admitted on March 27, 2024 and was still active at the time of the inspection. The release of information forms to the pharmacy and the laboratory were signed by the client on March 27, 2024, but both release forms did not include the specific information to be disclosed.
Client # 4 was admitted on March 14, 2024 and was still active at the time of the inspection. The release of information forms to the pharmacy and the laboratory were signed by the client on March 14, 2024, but both release forms did not include the specific information to be disclosed.
Client # 5 was admitted on March 7, 2024 and was still active at the time of the inspection. The release of information forms to the pharmacy and the laboratory were signed by the client on March 7, 2024, but both release forms did not include the specific information to be disclosed.
Client # 6 was admitted on February 20, 2024 and was discharged on March 4, 2024. The release of information forms to the pharmacy and the laboratory were signed by the client on February 20, 2024, but both release forms did not include the specific information to be disclosed.
Client # 9 was admitted on March 13, 2024 and was active at the time of inspection. The release of information forms to the pharmacy, probation and parole, and the laboratory were signed by the client on March 13, 2024, but all the release forms did not include the specific information to be disclosed.
Client # 10 was admitted on February 22, 2024 and was active at the time of inspection. The release of information forms to the pharmacy, probation and parole, and the laboratory were signed by the client on February 22, 2024, but all the release forms did not include the specific information to be disclosed.
Client # 11 was admitted on March 13, 2024 and was active at the time of inspection. The release of information forms to the pharmacy and the laboratory were signed by the client on March 13, 2024, but both release forms did not include the specific information to be disclosed.
Client # 12 was admitted on March 14, 2024 and was active at the time of inspection. The release of information forms to the pharmacy, probation and parole, and the laboratory were signed by the client on March 14, 2024, but all the release forms did not include the specific information to be disclosed.
Client # 13 was admitted on February 8, 2024 and was active at the time of inspection. The release of information forms to the pharmacy and the laboratory were signed by the client on February 8, 2024, but both release forms 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
Following the recent site-visit, separate release of information sheets were created for Pharmacy, and Laboratory use. These forms designate which is to used for each service. The forms also include areas for additional information to be added, as did the prior forms, but are exclusive to each service.
Only the forms specified with the designation of either. "Pharmacy" or "Laboratory" are now in-use: No other unspecified forms are available for these 2 specific purposes. This will ensure that no future options for lack of specificity are available.
The Director and Administrative Program Manager were responsible for this change and it's on-going utilization. |
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 for following the written procedures for the management of treatment services (notifying the emergency contact within 12 hours after a client is discharged from the facility against medical advice) was submitted and approved by the Department for the October 2, 2022, and October 17, 2023 annual licensing inspections. Failing to follow written procedures (notifying the emergency contact within 12 hours after a client is discharged against medical advice) was again found to be a deficiency in the March 25, 2024 plan of correction follow-up inspection.
A plan of correction for not completing and making available to the public an annual report was submitted and approved by the Department for the October 6, 2022 and October 17, 2023 annual licensing inspections. Failing to complete and make available an annual report was again found to be a deficiency in the March 25, 2024 plan of correction follow-up inspection.
A plan of correction for maintaining each bathroom in a functional, clean, and sanitary manner at all times was submitted and approved by the Department for the October 6, 2022 and October 17, 2023 annual licensing inspections. Failing to maintain each bathroom in a functional, clean, and sanitary manner was again found to be a deficiency in the March 25, 2024 plan of correction follow-up inspection.
A plan of correction for failing to complete an annual financial audit was submitted and approved by the Department for the October 6, 2022 and October 17, 2023 annual licensing inspections. Failing to complete an annual financial audit was again found to be a deficiency in the March 25, 2024 plan of correction follow-up inspection.
A plan of correction for ensure staff receive the communicable disease trainings were completed with the required timeframes was submitted and approved by the Department for the October 1, 2021, October 6, 2022, and October 17, 2023 annual licensing inspections. Failing to ensure staff receive the communicable disease trainings was again found to be a deficiency in the March 25, 2024 plan of correction follow-up inspection.
This is a repeat citation from the October 17, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The prior POC for this citation, was deemed to be followed-up on internal investigation, but there was a failure to document. Therefore, a separate communication sheet for the chart to remind and record such contacts. This form has now been required for all counselors. Monitoring staff, are to record such occurrences in their communication log.
We have now created a separate binder for this form for Monitors as well.
The instance of the current citation was investigated by the Director. The staff person in-question, stated that the call was made but he had failed to document it. We will be utilizing a separate binder along with on-going reminders in monthly meetings, which should aid in correcting this failure of action and documentation. In addition, if this action is required after regular business hours and the designated counselor is not present, they will be notified with a copy of the contact sheet in order that follow-up can be made, if necessary.
These steps will be implemented by the Administrative Program Manager and followed-up by the Lead Monitor. On-going compliance with the process will be reported to the Director.
The necessity for the Annual Report will be sent to the Board Chair and Comptroller, in order that steps be taken to fulfill this requirement.
The ACA Executive Director will meet in-person with the Board Chair, who is responsible for facilitating Corporate financial requests and documentation. Subsequently, the ACA Executive Director will also verify with accountant responsible for the report process that Annual Report will be finished as required.
The Executive Director will contact the Board Chair and Comptroller on a monthly basis via email, and discussed during the Board Chair in-person visits to ACA, to monitor the progress for the Annual Report Completion.
It will be conveyed to the Comptroller to have the Annual report completed one month prior to the date stated as final, as shown above.
Once the Annual Report is submitted to ACA, it will be published in a local paper to be made available to the public as required.
Facility review will be made with the Maintenance staff, with the implementation of a checklist and specific notations of prior deficiencies. Monthly facility reviews will include the Director.
All steps will be taken by the Facility Director to engage the Board Chair and Comptroller, whose responsibility it is to acquire the audited financials in a timely manner. This process will be monitored by the facility Executive Director, as stated in the above POC, to monitor the process.
The exact information regarding the impact on continued licensure will forwarded to the identified personal through email, phone contact and certified mail 3 months prior to the expected date. Completion of this financial will be requested to be sent to the Facility Executive Director by the date submitted above.
Trainings process identified in the current POC will be enacted to correct the lack of a more in-depth system of reminders for trainings and accountability.
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