INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18-20, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alpha House, 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
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of three personnel records on June 18, 2008, the facility failed to document that each counselor met the required qualifications in one personnel record, # 5. The counselor had a B.S. degree, however, the major was not verified. The employee represented by personnel record #5 also had less than one year of clinical experience.
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Plan of Correction
Counselor #5 has been changed to Counselor Assistant until such time that the requirements of supevision have been met. #5 has submitted a copy of the official transcript that list the major of psychology on it's in the personnel file. Close supervision will be conducted by the Residential Director and documented as such for six months. Alpha House will submit to the licensing department any such personnel qualifications for counselor in question for clarification and prevention of future occurances. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the result of a physical plant inspection, the facility failed to maintain the hot water temperature at or below 120 degrees Fahrenheit. Water temperature in the clients' bathroom was 160 degrees Fahrenheit.
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Plan of Correction
A new procedure has been implemented to test minimally on a monthly basis the temperature of the hot water, keeping it at 120 degrees Fahrenheit or below. This will be the responsibility of the Residential Director and documented in a file designated for this purpose. This procedure is effective July 3, 2008 and ongoing. |
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 the results of the physical plant inspection, the facility failed to keep cold foods at or below 40 degrees Fahrenheit and frozen food at or below 0 degrees Fahrenheit. Freezers were at 10 degrees Fahrenheit and 25 degrees Fahrenheit.
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Plan of Correction
Alpha House currently checks the temperature at 7am, 5pm, and 10pm. daily and a log is kept. In addition to our current procedure the Residential Director and/or designatee will be responsible for reviewing the temp. logs at the 5pm temp. time insuring correct tempertures after lunch and before dinner. Alpha House is purchasing an additional freezer to rectify the non-compliance. The Residential Director will initial his observance of the temperatures and take corrective action as indicated. Allegheny County Health Department (ACHD) also makes random visits to insure compliance. This procedure will be in effect July 21, 2008 with the purchase of a new freezer. |
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 the review of the fire drill logs, the facility failed to document that a fire drill was conducted during sleeping hours at least every six months. There were no fire drills conducted during sleeping hours within the past six months.
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Plan of Correction
Alpha House will revise the policy from "twice a year" to "every six months" and revise the information printed on the log to reflect the same. It will be the responsibility of the Executive Director to review the fire drill log for ongoing compliance. This is effective July 17, 2008 |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on the review of ten personnel records, the facility failed to verify the training experience in two records, # 3 and 5. In personnel record # 3, the major was not verified. In personnel record # 5, no training experience was documented.
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Plan of Correction
#3 will be required to produce a copy of their official transcript listing the major. This has been corrected and is in the personnel file, in the Executive Director's office.
#5 Residential Counselor position has been changed to Counselor Assistant until such time all required training has been officially documented. Supervision is currently being conducted by the Residential Director with documentation. This is currently being corrected as of licensing visit, June 20, 2008. Alpha House will submit to the licensing department any such personnel qualifications for the position of Counselor in question for clarification and prevention of future occurances. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of six client records, three were required to have follow-up information. The facility failed to document follow-up information in one of three client records reviewed, # 4. There was no follow-up documented.
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Plan of Correction
The procedure for follow up has been changed. Upon discharge the file will be given to the Executive Director who will be responsible for making a follow up attempt and documentation of the attempt will be placed in the clients file. This procedure is in effect as of July 1, 2008 |