INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2007 through November 7, 2007 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on December 6, 2007.
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Plan of Correction
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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 conducted on November 7, 2007 and interview with facility staff, the facility failed to provide documentation that all mattresses were fire retardant.
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Plan of Correction
Corrections will be made within 90 days. All mattresses/box springs will be fire retardant, documentation will be kept on file and updated as new mattresses are acquired . Deficiency was the responsibility of the Director. |
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 conducted on November 7, 2007, the facility failed to provide slip-resistant surfaces in the bathtubs in five of six bathrooms.
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Plan of Correction
Correction will be made within 30 days. All bathtubs will have slip resistant surfaces installed. Monthly inspections from maintenance will be conducted to assure compliance. Deficiency was the responsibility of the Director. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on a review of the projects's policy and procedure manual and the facility's disaster/risk management plan, the facility failed to provide written procedures for staff and residents to follow in case of an emergency that included provisions for the evacuation and transfer of residents impaired by alcohol or other drugs.
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Plan of Correction
Corrections were made immediately. Our policy includes provisions for the evacuation and transfer of residents that are impaired by alcohol or other drugs. The deficiency was the responsibility of the Director. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill record, the facility failed to conduct a fire drill during sleeping hours from December 2006 to June 2007.
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Plan of Correction
Corrections were made immediately. We will conduct fire drills during sleeping hours to ensure compliance. Fire drill logs will be reviewed monthly by our maintenance department. Deficiency was the responsibility of the Director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in three of five records reviewed, #1, 3 and 4. The psychosocial evaluation did not assess the client's presenting and underlying problems or provide an assessment of the available or potential support system in record #1. The psychosocial evaluation did not include as assessment of the client's available or potential support systems and negative factors that may inhibit treatment in record #3. The psychosocial evaluation did not include an assessment of the client's available or potential support systems and coping mechanisms in record #4.
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Plan of Correction
The clinicians have received a copy of the states regualtions regarding BPS compliance, the charts will be reviewed monthly by the Director. The deficiency was the responsibility of the Director. |
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 the client records, the facility failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in three of five records reviewed, #1, 4 and 5.
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Plan of Correction
Corrections were made immediately. Clinicians were informed of the expectation and treatment plans will be reviewed monthly by the Director. Deficiency was the responsibility of the Director. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of the client records, the facility failed to document complete group progress notes in four of four client records reviewed, #1, 2, 3 and 4. The group notes did not include either the counselor's assessment of the treatment session or a plan.
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Plan of Correction
Correction were made immediately. The progress notes have been changed to meet the expectation. Clinicians have been informed of the expectation, notes will be reviewed by the Director monthly to ensure compliance. The deficiency was the responsibility of the Director. |