INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18-20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alpine Springs Rehabilitation & Recovery Center, LLC 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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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Reviewed fire drill logs from January 2023 through November 2023. There was no documentation of a fire alarm or smoke detector being set off during the October 2023 fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Alpine Springs as a policy that meets DDAP compliance. Alpine follows this process and the staff conducting the drill ensures the fire alarm is set off for each drill. We have an electronic reporting system where the staff conducting the drills completes the form online. During the October drill, the manager conducting the drill failed to click that the fire alarm was set off, but verifies it was. To prevent this from reoccurring, the electronic process was changed. the staff completing the drill will complete the form, and it will go to the facility director to review for any non-compliance or errors. If approved, the facility director will have the second signature on each drill. This process was updated January 2024, and in compliance. The facility director is responsible for the overall compliance of this standard deficiency and corrective action plan. |
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 a review of the administrative information, the facility failed to provide all required policy, procedures, and plans.
The following policy and procedures did not contain all necessary components to meet regulation standards:
-704.11a- Staff development program for completion time frames
-705.9(4)iii- for the evacuation and transfer of residents under the influence in an emergency situation
-709.34(a)2, 4, 6, 7, 8- Incident report policy and procedure does not include selling or use of illicit drugs on premise; significant disruption of services due to a disaster such as fire, storm, flood, or other occurrence which closes the facility for more than one day; event at the facility requiring the presence of police, fire, or ambulance personnel; fire or structural damage to the facility; and outbreak of a contagious disease requiring CDC notification.
-709.34(b)2, 3, 4- Incident report policy and procedure does not include prompt review and identification of the causes directly or indirectly responsible for the unusual incident; implementation of a timely and appropriate corrective action plan, when indicated; and ongoing monitoring of the corrective action plan.
The following policy and procedures were not provided:
-709.5(d) an outreach plan for the residential activity
-709.64(f) an outreach plan for the detoxification activity
-709.26(a)1 personnel management for utilization of volunteers
-709.32(c)5 for the security of drugs including loss, theft or misuse of drugs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Alpine's project director annually prepares, annually update and signs a written manual delineating project policies and procedures. The following policies were added or revised to meet the following standards:
704.11a: Staff development program policy was created in January 2024 which outlines the process and timeframes. Human resources will be responsible for the tracking of times, the same process as the training plans in our electronic HR system. The facility director will be responsible for the compliance of this standard deficiency.
705.9 (4)ii: For the evacuation and transfer of residents under the influence in an emergency situation, our policy EC-01 Disaster codes and responses policy was revised to include:
7. Clients requiring assistance during evacuation
Evacuation process for individuals requiring additional assistance:
- Individuals identified as requiring additional assistance include, but are not limited to:
o Clients that are currently admitted to 3.7WM level of care
o Clients that are currently under the influence of drugs and/or alcohol
o Clients that require assistive devices for ambulation (walkers, crutches, prosthetics, etc.).
- Clients that meet the above criteria will be identified by "(A)" on the client census, to ensure employee awareness while allowing the information to remain confidential to client peers.
- In the event of an evacuation, senior staff on duty will assign one staff member per client in need of assistance.
o The assigned staff will provide one-on-one support to the client during the evacuation process.
- If staffing does not allow for one-on-one assistance, nursing will be responsible for triaging the identified clients and assigning staff to assist as needed.
Staff will be trained on this updated policy in the January staff meeting and sign off on the policy. the Census was updated to identify any clients needing assistance. Nursing supervisor will monitor the ongoing compliance of this when reviewing the census daily. ten facility director is responsible for the overall compliance of this standard deficiency.
709.34(a)2, 4, 6, 7, 8; 709.34(b)2, 3, 4
Alpine Springs updated our policy RM-02: Reporting of unusual incidents to now include:
selling or use of illicit drugs on premise; significant disruption of services due to a disaster such as fire, storm, flood, or other occurrence which closes the facility for
more than one day; event at the facility requiring the presence of police, fire, or ambulance personnel; fire or structural damage to the facility; and outbreak of a contagious disease requiring CDC notification. Also added was prompt review (24-72 hours), identification of the causes directly or indirectly responsible for the unusual incident; implementation of a timely and appropriate corrective action plan (will be completed by manager and signed off by director within 7 days), when indicated; and ongoing monitoring of the corrective action plan. The process is already in place and we are meeting the standards, our policy was just not updated to reflect what we were doing and the timeframes. The policy is now in compliance. The facility director is responsible for the ongoing monitoring and compliance of this standard's deficiency.
709.5(d), and 709.64(f):
Alpine Springs did not have outreach plans for both detox and residential services. The director of marketing and project manger developed a plan for each service provided which includes:
1. Alpine Springs establishes relationships with several community organizations that assist in identifying those in need of our services. This includes other treatment facilities, community outreach programs, County SCAs, County Drug and Alcohol Programs, local Court systems, and recovery-based organizations. Alpine Springs also receives reporting from local hospitals, coroner's reports, and SCAs.
2. Alpine Springs uses the relationships with the aforementioned sources, in addition to online advertising, social media, email, flyers, and our Employer Assistance Program to communicate the availability of our services. Alpine Springs is also a member of all surrounding local area Chambers of Commerce.
3. Alpine Springs has an admissions team that monitors those that want to utilize our services and assists with the intake process. Once someone inquiries about our services through any medium, a member of our admissions team will monitor their progress throughout the intake process.
The administrative team all plays a role in the compliance of this plan. The project director is responsible for the compliance of this corrective action plan and will review/update them each annually. the facility director will monitor the compliance of this.
709.26(a)1:
Alpine Springs did not have a policy on personnel management for utilization of volunteers. A policy was created in January 2024, and implemented then. HR created the policy, Utilization of Volunteers Policy, and the director of HR is responsible for the ongoing compliance of the policy, and the facility director responsible for compliance of this action plan.
709.32(c)5:
Alpine Springs was not compliant in having a policy for the security of drugs including loss, theft or misuse of drugs. Med-25 Medication Misuse policy was created in January 2024. The policy includes:
All medications shall be managed using the proper Alpine Springs protocols, found in MED-02. If any discrepancies are found, or medication misuse is suspected, the following process will be enacted.
The suspecting staff, or client, will immediately report their suspicion to the nursing supervisor.
The nursing supervisor, along with the program director, will review any information provided by the accuser.
All information will be conveyed to Alpine Springs' CEO and human resources department.
An internal investigation will conducted by the program director, human resources, the nursing supervisor, and the accused individual's supervisor.
An in-person interview with the accused will be conducted, if found to be necessary during the internal investigation.
If the claim is found to be substantiated, disciplinary action will taken on the employee up to, and including termination.
If applicable, the incident will be reported to the Pennsylvania state board of licensing by the program director.
The Nursing supervisor will train staff on this policy in the January 2024 staff meeting and monitor compliance via routine audits and incident reports. The facility director will monitor compliance of this via incident reporting system and process in place.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based a review of personnel records, the facility failed to provide documentation of annual written individual staff performance evaluations reviewed and signed by the employee, in three of four applicable records.
Employee #2 was hired on January 31, 2022 and promoted to Facility Director on December 12, 2022. An electronic annual performance evaluation which included an employee self-assessment as well as manager assessment did not include the dated signature of the employee.
Employee #3 was hired on November 16, 2020 and promoted to clinical supervisor on January 11, 2021. An electronic annual performance evaluation which included an employee self-assessment as well as manager assessment did not include the dated signature of the employee.
Employee #4 was hired on February 15, 2022 and promoted to counselor on September 4, 2023. An electronic annual performance evaluation which included an employee self-assessment as well as manager assessment did not include the dated signature of the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.26. Personnel management.
Alpine Springs was compliant on annual staff evaluation, the policy, timeframes, and completion of them complied. Alpine's process is through the electronic HR system, Bamboo, and shows the electronic name, date and time of the signing of the completion of the self-evaluation by the employee, and the electronic name, date, and time of the manager who completed the annual evaluation. The electronic system does not allow for the signature of the employee and manager on the actual evaluation. The plan of correction for this includes; Alpine created a signature page for the staff and manager to sign and complete along with the annual evaluation to meet this standard. HR has implemented this process starting January 2024, and the facility director is responsible for the compliance of this plan of correction.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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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 which includes a relevant purpose of the disclosure, in four of fourteen client records.
Client #3 was admitted to detox treatment on July 7, 2023 and was discharged on July 16, 2023. Two release of information forms to government agencies were signed by the client on July 7, 2023. Both release forms indicated "Pa 255" as the purpose; however, this was not a relevant purpose of the disclosure for the two agencies.
Client #6 was admitted to detox treatment on September 14, 2023 and was discharged on September 18, 2023. A release of information form to an individual was signed by the client on September 18, 2023. The release form indicated "Pa 255" as the purpose; however, this was not a relevant purpose of the disclosure for the individual.
Client #12 was admitted to residential treatment on August 21, 2023 and discharged October 10, 2023. A release of information form to an agency was signed by the client on August 23, 2023. The release form indicated "release of information" as the purpose; however, this was not a relevant purpose of the disclosure for the agency.
Client #13 was admitted to residential treatment on November 16, 2023 and was still active at the time of the inspection. A release of information form to a funder was signed by the client on November 16, 2023. The release form indicated "insurance" as the purpose; however, this was not a relevant purpose of the disclosure for the agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28. Confidentiality:
Alpine springs has added the purpose of disclosure to our release of information form in our electronic medical record to include more specific purposes for each consent. The policy was also updated to be specific on the purpose. All staff will be trained to in the January 2024 staff meeting. The clinical supervisor will monitor the compliance of this on the monthly audits and the facility director will be responsible for the overall compliance of this standard deficiency.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in five of fourteen client records.
Per the policy and procedure, medications are checked off on Medication Administration Record (EMAR).
Client #4 was admitted to detox treatment on September 19, 2023 and was discharged on September 25, 2023. A progress note indicated a medication was given on September 25, 2023 but it was not documented on a Medication Administration Record.
Additionally, " no shows " are indicated as a yellow highlight on the Medication Administration Record but there was no documentation as to why the medication was not given as prescribed in client records # 3, 8, 13 & 14.
Client #3 was admitted to detox treatment on July 7, 2023 and was discharged on July 16, 2023. No shows are indicated on the Medication Administration Record for July 14, 2023.
Client #8 was admitted to detox treatment on May 8, 2023 and was discharged from residential treatment on May 18, 2023. No shows are indicated on the Medication Administration Record on May 17, 2023.
Client #13 was admitted to residential treatment on November 16, 2023 and was still active at the time of the inspection. No shows are indicated on the Medication Administration Record on November 28, 2023
Client #14 was admitted to residential treatment on December 4, 2023 and was still active at the time of the inspection. No shows are indicated on the Medication Administration Record on December 16 and 17, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.32. Medication control.
709.32 (c)(1)(i)-(ii) - Policy MED-01 Medication Administration updated to reflect guidelines requiring documentation of clients that do not attend morning med pass, refusal by absence. Staff will be educated on and required to sign off on the updated policy. Staff will receive additional training during the January 2024 monthly staff meeting. All staff will sign off on the updated policy. The nursing supervisor will add this to the monthly audit to monitor staff compliance, and the facility director will monitor the compliance of this corrective action plan by signing off on the audits each month. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to provide documentation of the project notifying the client, in writing, of the reason for their involuntary termination, in two of two applicable records.
Client #10 was admitted to residential treatment on September 26, 2023 and discharged on October 18, 2023. There was no documentation in the client record notifying the client of the specific reason for their termination from the project.
Client #12 was admitted to the detoxification activity on August 17, 2023, stepped down to residential treatment on August 21, 2023, and was discharged on October 10, 2023. There was no documentation in the client record notifying the client of the specific reason for their termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.33. Notification of termination.
Alpine Springs has created a new policy, Notification of termination policy. This policy will be trained at the January staff meeting. Process will be: As a client is being discharged, they will sign a summary of the discharge at the time of discharge, which includes the reason. This summary will include the reason for termination and a box to mark if they want the opportunity to request reconsideration of the decision to terminate treatment, and how to be contacted. The clinical supervisor will be responsible for auditing tis in the monthly audits, and the facility director will be responsible for the compliance in this standard deficiency by signing off on the monthly audits.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide documentation of the project providing clients the opportunity to request reconsideration of a decision terminating treatment, in two of two applicable records.
Client #10 was admitted to residential treatment on September 26, 2023 and discharged on October 18, 2023. There was no documentation in the client record providing the client the opportunity to request reconsideration of the decision terminating treatment.
Client #12 was admitted to the detoxification activity on August 17, 2023, stepped down to residential treatment on August 21, 2023, and was discharged on October 10, 2023. There was no documentation in the client record providing the client the opportunity to request reconsideration of the decision terminating treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.33. Notification of termination.
Alpine Springs has created a new policy, Notification of termination policy. This policy will be trained at the January staff meeting. Process will be: As a client is being discharged, they will sign a summary of the discharge at the time of discharge, which includes the reason. This summary will include the reason for termination and a box to mark if they want the opportunity to request reconsideration of the decision to terminate treatment, and how to be contacted. The clinical supervisor will be responsible for auditing tis in the monthly audits, and the facility director will be responsible for the compliance in this standard deficiency.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in six of seven applicable residential records reviewed.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in the following records:
Client #2 was admitted to residential treatment on July 15, 2023 and discharged July 27, 2023.
Client #7 was admitted to residential treatment on November 11, 2023 and still a current client.
Client #10 was admitted to residential treatment on September 26, 2023 and discharged October 18, 2023.
Client #12 was admitted to residential treatment on August 21, 2023 and discharged October 10, 2023.
Client #13 was admitted to residential treatment on November 16, 2023 and still a current client.
Client #14 was admitted to residential treatment on December 4, 2023 and still a current client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Alpine Springs will update the CS-05 policy; Treatment planning and support services to include whether or not work done and life skills groups will be an integral part of the treatment and rehabilitation plan for each individual case.
Alpine Springs is updating the master treatment plans to have a separate one for detox and residential services. The residential master treatment plan will include assigned daily chores for the development of life skills, life skill practices, and individual responsibilities. As these are determined to be part of the treatment for a client, the counselor will implement this in their master treatment plan. Life skills groups are offered weekly, will be assigned to those clients by their counselor when it would beneficial for their treatment to attend . This will be reflected on the master treatment plan, as well as the weekly client schedule discussed between the counselor and client.
The clinical supervisor will monitor the compliance of this via monthly audits and the facility director will review the audits to ensure compliance in this standard deficiency. |