INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7, 2011 through September 8, 2011 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:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications and the facility's staff work schedules from August 8, 2011 to September 8, 2011, the facility failed to ensure that a sufficient number of staff persons in first aid and CPR skills are present during all the project's hours of operation.
The findings include:
On September 8, 2011, the facility's personnel records were reviewed. Also, from September 7, 2011 to September 8, 2011, the facility's first aid cards, CPR certifications, staff work schedule for people who had first aid training and current CPR certification from August 8, 2011 to September 8, 2011 were reviewed. Based on the work schedule from August 8, 2011 to September 8, 2011 that was provided by the facility, the facility did not have first aid and CPR coverage on the following days and times listed below.
1. From 8:00 P.M. on August 8, 2011 to 8:00 A.M. on August 9, 2011.
2. From 10:00 P.M. to 11:30 P.M. on August 9, 2011.
3. From 5:30 P.M. on August 10, 2011 to 7:30 A.M. on August 11, 2011.
4. From 7:00 P.M. on August 11, 2011 to 12:30 A.M. on August 12, 2011.
5. From 4:00 P.M. on August 12, 2011 to 12:30 A.M. on August 13, 2011.
6. From 4:30 P.M. on August 13, 2011 to 12:00 P.M. on August 14, 2011.
7. From 7:30 P.M. on August 14, 2011 to 7:30 A.M. on August 15, 2011.
8. From 8:00 P.M. on August 15, 2011 to 8:00 A.M. on August 16, 2011.
9. From 10:00 P.M. to 11:30 P.M. on August 16, 2011.
10. From 5:30 P.M. on August 17, 2011 to 7:30 A.M. on August 18, 2011.
11. From 7:00 P.M. on August, 18, 2011 to 12:30 A.M. on August 19, 2011.
12. From 4:00 P.M. on August 19, 2011 to 12:30 A.M. on August 20, 2011.
13. From 4:30 P.M. on August 20, 2011 to 12:00 P.M. on August 21, 2011.
14. From 7:30 P.M. on August 21, 2011 to 7:30 A.M. on August 22, 2011.
15. From 8:00 P.M. on August 22, 2011 to 8:00 A.M. on August 23, 2011.
During an interview with the Administrative Assistant conducted on September 8, 2011 at approximately 9:15 A.M., the findings were confirmed.
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Plan of Correction
The Executive Director is responsible for this deficiency and he will monitor continued compliance. All staff will be trained in both CPR and First Aid before being added to the schedule. Correction is completed. The correction was already completed at the time of inspection. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observations on September 8, 2011, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on September 8, 2011. During the inspection, at approximately 10:48 A.M., it was observed that the facility had a dumpster in the rear of the building. The dumpster was missing one of the four lids and the other three only partially covered the dumpster.
During an interview with the maintenance man conducted on September 8, 2011 at approximately 10:55 A.M., it was confirmed that the dumpster was only partially covered with lids and that one lid was missing.
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Plan of Correction
The Executive Director is responsible for this deficiency and will monitor continued compliance. This was corrected the day after inspection. We contacted our trash service company and had them bring us a new dumpster with a solid, functioning lid. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a review of the facility's written procedures for staff and clients to follow in case of an emergency, and a discussion with the maintenance man and project director, the facility failed to provide written procedures for staff and clients to follow in case of an emergency for the evacuation and transfer of residents and staff to a safe location.
The findings include:
On September 8, 2011, the Licensing Specialist asked if the facility had experienced any problems with bed bugs. The maintenance man indicated that the facility had two incidents with bed bugs. The maintenance man stated in September 2010, the facility had an infestation of bed bugs on the second floor in the rear bed room of Apartment # 440. The maintenance man also stated in February 2011, the facility had another infestation of bed bugs on the third floor in the rear bed room of Apartment # 440. The maintenance man further stated that the infestation of bed bugs in both of the bed rooms and at the facility were resolved in the same month of the incidents.
Also, on September 8, 2011, the Licensing Specialist asked if the facility had a written policy and procedure in place to deal with bed bugs. A policy and procedure to deal with bed bugs was not presented for review.
During an ongoing dialogue with the maintenance man conducted on September 8, 2011 at approximately 11:00 A.M to 12:00 P.M., the findings were confirmed.
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Plan of Correction
The Executive Director assumes full responsibility both for the citation and continued monitoring of its future compliance. Once the problem was identified, several months back, immediate steps were taken to mitigate the problem. In this instance, it did not necessitate the need for the evacuation of patients, but ACA does have a comprehensive evacuation plan and policy if it would have been necessary. The Executive Director also composed a policy and included it in the procedures manual to cover future continuities. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information.
The findings include:
On September 8, 2011, five records were reviewed for informed and voluntary consents to release information. The facility released information without the client's consent in client in two of five records reviewed, records # 2 and 5.
Client record # 2 contained Eligibility Verification System forms dated 8/17/11, 8/22/11, 8/26/11, and 8/29/11 in which the facility released information about the client to a government agency, but the facility did not document a signed consent from the client to release the information.
Client record # 5 contained Eligibility Verification System forms dated 6/21/11, 7/5/11, 7/13/11, 7/16/11, 7/19/11, 7/23/11, 7/26/11, 8/2/11, 8/8/11, 8/10/11, 8/17/11, 8/17/11, 8/26/11, and 8/29/11 in which the facility released information about the client to a government agency, but the facility did not document a signed consent from the client to release the information.
During an ongoing dialogue with the lead counselor conducted on September 8, 2011 from approximately 3:00 P.M. to 3:15 P.M., the findings were confirmed.
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Plan of Correction
The Director assumes responsibility for this citation and the future monitoring of its compliance. The citation was addressed by completely modifying our release of information, including anything that would be released to the Department of Public Welfare i.e. case reviews, funding continuances and EVS. Record # 2 was already discharged and record # 5 was in fact corrected. |
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 document an individualized individual treatment and rehabilitation plan with the client.
Also based on a review of client records and an interview with the lead counselor, the facility failed to document an individual treatment and rehabilitation upon the completion of the psychosocial history and psychosocial evaluation in one of five records reviewed.
The findings include:
The facility's policy titled: "Treatment Planning," states:
"The initial treatment should be developed within seven days after admission.
The treatment plan should reflect the following:
1. Short and long term goals as formulated by the primary therapist and client as is reflected in the Bio-psycho-social form.
2. The type and frequency of treatment and rehabilitative service.
3. The type and frequency of treatment and rehabilitative service.
4. The regular treatment plan will be formulated within 7 days of admission."
On September 8, 2011, five client records were reviewed for documentation of an individual treatment and rehabilitation plan. The facility did not document an individualized treatment and rehabilitation plan in five of five records reviewed, records # 1, 2, 3, 4, and 5.
Client # 1 was admitted August 1, 2011. The individual treatment and rehabilitation plan was completed on August 4, 2011; however, the psychosocial history and psychosocial evaluation was completed on August 5, 2011. Also, the individual treatment and rehabilitation plan contained objectives, goals, type and frequency, and proposed type of support services that were nearly identical to the individual treatment and rehabilitation plan in client records # 2, 3, 4, and 5.
Client # 2 was admitted August 4, 2011. The individual treatment and rehabilitation plan was completed on August 9, 2011, but contained objectives, goals, type and frequency, and proposed type of support services that were nearly identical to the individual treatment and rehabilitation plan in client records # 1, 3, 4, and 5.
Client # 3 was admitted June 15, 2011. The individual treatment and rehabilitation plan was completed on June 20, 2011, but contained objectives, goals, type and frequency, and proposed type of support services that were nearly identical to the individual treatment and rehabilitation plan in client records # 1, 3, 4, and 5.
Client # 4 was admitted June 21, 2011. The individual treatment and rehabilitation plan was completed on June 22, 2011, but contained objectives, goals, type and frequency, and proposed type of support services that were nearly identical to the individual treatment and rehabilitation plan in client records # 1, 2, 3, and 5.
Client # 5 was admitted June 13, 2011. The individual treatment and rehabilitation plan was completed on June 15, 2011, but contained objectives, goals, type and frequency, and proposed type of support services that were nearly identical to the individual treatment and rehabilitation plan in client records # 1, 2, 3, and 4.
During an ongoing dialogue with the lead counselor on September 8, 2011 from approximately 3:00 P.M. to 3:15 P.M., the findings were confirmed.
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Plan of Correction
The Executive Director assumes responsibility for this citation and the future monitoring of its compliance. All treatment documents including the Initial Treatment Plan are individually tailored to specifically relate to the therapeutic need of the client and will be monitored more closely by the Executive Director to assure full compliance with this regulation. This modification has been changed effective the date of inspection. |