INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual, written individual training plan for each employee, appropriate to that employee's skill level and with input from both the employee and the supervisor, in one of four personnel records reviewed.
Employee # 3 was hired as a counselor on May 9, 2022. There was no individual training plan documented for the current year in the personnel record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An individual training plan had been completed by the Director and each counselor prior to the Licensing visit.
Employee #3 had retained the plan for copying and personal notation. At the time of the Site visit, he could not locate the required document.
To further insure that training plans are available as required, they will be given to the Administrative Program Manager, immediately upon completion and copied if requested, and retained for further review as needed. The Director and Administrative Program Manager will be responsible for taking this additional step to assure all plans are available when needed. |
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 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 training within the regulatory timeframe in two of two applicable personnel records reviewed.
Employee # 1 was hired as the project director/facility director on December 15, 2021 and was due to have the HIV/AIDS training and the TB/STD training no later than December 15, 2023. There was no documentation indicating the HIV/AIDS training and the TB/STD training were completed as of the date of the inspection.
Employee # 4 was hired as a counselor on July 21, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than July 21, 2024. There was no documentation indicating the HIV/AIDS training and the TB/STD training were completed as of the date of the inspection.
This is a repeat citation from the October 1, 2021, October 6, 2022, and October 17, 2023 annual licensing inspections and the March 25, 2024 plan of correction follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee @1 did not receive the certificate of completion from his prior employer for the require courses and did not re-complete them before the due date. Employee #4 did not complete a course with the correct number of courses needed.
Both employees will have completed the necessary courses no later than inform the Board Chair that the needed courses12/10/2024. The POC includes that Employee #4, a part-time employee was provided with the information for the correct course by the APM. Employee #1 will also complete the required courses by the same date. Employee #1,reporting to the Board Chair will keep him informed of that requirement, as part of the weekly update of that completion, as part of the update on the progress report on the deficiencies received as on the licensing review subsequent to the recent licensing status. Both employees will not be required to repeat these courses again. However, as stated previously, all staff course requirements will need to be submitted prior to course selection to the APM, and approved before starting them and completion certificate copies submitted after they are finalized. Employee #1 will submit this information to the Board Chari for licensing requirements.
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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 and staff schedules, the facility failed to ensure there was a sufficient number of staff persons certified in CPR and trained in first aid, so that at least one person trained is onsite during the project's hours of operation.
The staff schedules for the time period of September 9, 2024 through October 6, 2024 were reviewed. The facility provides inpatient rehabilitation services and the hours of operation are 24 hours per day and 7 days per week. There was no staff person, currently certified in CPR and trained in first aid, working onsite at the facility from 5:00 PM to 11:45 PM on September 12, 2024 and from 5:00 PM to 12:00 AM on September 13, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All required ACA Staff receive CPR training. Such staff are hired and during the course of the training period complete the required trainings, providing such trainings are available. In the instances of staff calling-out for their stated work period, newly hired staff who had not completed CPR training were utilized.
The Plan of Correction will not permit new hires to work other than training, without completion of all required trainings, which include CPR. Therefore they will not be allowed/available to be scheduled in a capacity where that is required.
To further enhance this, new staff will be scheduled to begin employment during a week when CPR Training is known to be available. The Administrative Program Manager will be directly oversee this activity. New hire on-boarding will also be reviewed for start date with the Executive Director to further ensure this is carried out. Lastly, a notification to the Lead Monitor and all Monitoring staff as to this change has been effected.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director completed at least 12 clock hours of annual training during the facility's October 1, 2023 through September 30, 2024 training year in one of one applicable personnel record reviewed.
Employee # 1 was hired as the project director/facility director on December 15, 2021. The personnel record documented 0 hours of training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 had completed several courses within the topic areas, prior to the inspection. The remainder of the needed courses will be completed by the above date. Now cognizant of this requirement, Employee #1 will make the Board Chair aware of the due date and review the progress toward completion. The, APM who assists with Employee #1's calendar, will assist with reminder, toward aiding in having the deadline, and available courses chosen and therefore completed. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's October 1, 2023 through September 30, 2024 training year in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 9, 2022. The personnel record documented 0 hours of training during the training year reviewed.
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
Employee #3 had selected a the required courses and had submitted the training topics to the APM and Executive Director. Unfortunately, he was not able to complete the coursework at the time of the site visit. Subsequently, the Executive Director met with this employee to verify the course work and the timeframe needed to complete it. Reviewing the current citation and necessity that all hours would need completion by the date shown above, which reflects the ability to accomplish all the hours.
As previously stated; all employees requiring trainings must now submit a printout of the trainings to be taken to the APM and to be reviewed and followed-up with the Executive Director to assure that they provide the necessary topic(s) and hours. The designated work will be reviewed by the date the employee states, and is shown by the training provider. As it relates to employee #3, the trainings need to be completed by the date provided above. |
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 clean, safe, sanitary, and in good repair at all times for the safety and well-being of residents, employees, and visitors.
There was a staff office in the basement of building # 440 that was dirty, dusty and had a black substance in what appeared to be mold on the floor and walls. Additionally, the carpet in the lounge area and the stairs of building # 440 was ripped and stained, and one specific tear was held together with tape, which created a tripping hazard. Also, the administrative office in building # 438 had a hole in the ceiling, which exposed the inner portion of the ceiling.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff office inbuilding #440 had been out of use for a six month period and was not being routinely inspected. The entire building had been previously checked for mold by an external company The black substance was not mold. However, on 10/08/2024, the room was completely cleaned and disinfected. As we are now aware that a empty office must still be routinely inspected it will be placed on our list to be cleaned. if needed, on a weekly basis by our maintenance staff, and checked monthly by the Administrative Program Manager and/or Lead Monitor.
The POC for the ripped and stained carpeting in building #440 included a meeting with the primary maintenance staff and the APM. The taped carpet area in the lounge area was immediately replaced with new carpet tape and adhered, so as not to be a potential tripping hazard, as an interim measure. Maintenance staff, will attempt to patch any ripped carpet areas in such a manner as not to require carpet tape. If tape is the only measure, it will be inspected weekly by the maintenance staff, and replaced. Attempts to eradicate the staining will be made by maintenance staff using a commercial carpet cleaner. Future and more inclusive corrections may be possible with funds made available through fiscal endeavors by the Executive Director. This would allow for the replacement of the carpeting in the lounge area after Board approval.
Ongoing maintenance of the lounge area and steps for staining and tears, or tripping hazards, will be reviewed weekly by the APM and corrected if needed, by maintenance. Reports of needed corrections will be made to the Executive Director, to then be reported to the Board Chair and Board, to potentially aid in procuring funding for replacement carpeting.
The exposed hole in the ceiling in building #438, had been a recurring issue at ACA. It had been repaired almost 3 years prior under the former Executive Director and reoccurred twice during the current Director's term. As the second reoccurrence of a water leak was slight, and no previous citations were made, it was determined that more in-depth attempts to locate the current source of the leak and make a more in-depth repair. Plumbing repair had been made but the cosmetic covering of the hole had not been undertaken at the time of the site visit. However, this was completed on 10/11/24. Primarily, the Executive Director, with assistance of the APM, and maintenance, when possible, is responsible for reporting major needed repairs in the facility to the Board Chair. This would occur after gathering information and pricing as to what is required to correct the presenting problem.
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain the furnishings of the living room/lounge area in a state of good repair.
At the time of the inspection, in the living room of building #440, there was a couch and a chair that were stained and there was a second couch that was stained and torn.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The living room/Group Room, which serves the purpose for all larger clinical group and non-clinical purposes is frequent use by clients. At the time of inspection a one inch tear on the lower flap of one couch was noted upon inspection. This was repaired on 10/28/2024. Staining that was present at the time of that inspection will be addressed by cleaning and shampooing of the couches to attempt removal by the above mentioned date. The integrity and appearance of furnishings will added to the areas of inspection on a routine basis to assist in preventing further unaddressed areas.
This activity will be conducted by the Lead Monitor, and Administrative Program Manager, and approval for an required expenses to the Director, and in the event that any action is required.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
At the time of the inspection, the staff bathroom, located in the basement of building # 440, did not have an operable soap dispenser and paper towels or a mechanical dryer.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bathroom in the basement of building #440 is utilized by one staff member who has notified the Administrative Program Manager,(APM) when paper towels, soap, or a soap dispenser is needed, which this individual routinely attends to. At the time of the site visit this had not been done and therefore not replaced. On the above date these products were resupplied to this bathroom with additional towels in that room. A notice was placed in the bathroom stating that all items must be continually replaced at once, and the APM notified. As this person is a part-time staff, this area will also be included on the weekly rounds performed by the APM and maintenance staff.
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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 all facility heaters were permanently mounted or installed as there was a space heater located in the counselor's office in the basement of building # 440.
This is a repeat citation from the October 17, 2023 annual licensing renewal inspection and the March 25, 2024 plan of correction follow-up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Subsequent to the prior citation all steps were followed as stated in the previous POC. However, unbeknownst to the administrative staff a space heater was placed in the basement office by a new hire thinking it could be helpful to the part-time employee utilizing that space. The heater was not being used but was stored in that office space.
The POC involved making all current staff aware of that such heaters are not to brought into the premises. The heater that was present was immediately removed. The presence of any space heaters was added to the checklist for maintenance staff as well ,as an item not to be allowed on the premises.
Persons responsible for directly enacting this activity are the lead monitor, maintenance staff, APM, with weekly checklists being reported to the Executive Director. |
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 physical plant inspection, the facility failed to ensure the premises was free of rodent and insect infestation.
At the time of the inspection, the basement of building # 440 was infested with what appeared to be gnats.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACA is contracted with Ehrlich Pest Control services who visit the site monthly. Their representative inspects all areas of the building for the presence of insects and rodents. Any signs of recent activity are reported to the APM and Executive Director. The office which was cited, had never been made mention of, and was visited by an ACA staff member, and both the APM and Executive Director immediately after the Licensing visit. No trace of insects of any type were seen at that time.
As there was a presence of any insects in the office, though transient in nature, it was sanitized and a conventional brand of insect spray utilized. To further ensure that that space will remain insect free, the APM made Ehrlich aware that that space must be concentrated on for any future visits. On going monitoring of that space in particular has been added to the facility checklist revue, to aid in avoiding any further reoccurrence. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all stairways, hallways and exits from rooms and from the residential facility were unobstructed.
At the time of the inspection, the fire exit, located in the basement of building # 440, was blocked and obstructed by a dresser.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Unbeknownst to Administrative Staff, a piece of furniture was placed in the basement area, by a recently discharged Maintenance person, who was previously charged with assuring that any facility approved material was to be brought onto the premises and certainly not place in an obstructive location. Any further access to that individual has been restricted. This item was removed on the date stated. Going forward this area will be checked not only by maintenance staff, but routinely by the Lead Monitor and Administrative Program Manager on routine weekly rounds of the premises. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection, the facility failed to maintain an operable, automatic smoke detector on each floor, including the basement and attic.
At the time of the inspection, the smoke detector in the basement of building # 440 kept beeping roughly every minute, which indicated an operational issue. A conversation with facility staff confirmed this had been going on for over one month.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACA utilizes Tilley Fire Solutions for maintenance and any needed repairs to that system. This company was called to inspect the beeping smoke detector in the basement of building #440. Tilley representatives found that there was a "short" in the wiring system, resulting in the intermittent triggering of the sound, resulting form any threshold of movement in the building that resulted in that effect on the wiring.
All staff were made aware that any such unusual activity of that system should be immediately reported to the PM and or Executive Director for action to be taken to engage Tilley's services again. |
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 # 4 was admitted on June 26, 2024 and was discharged against medical advice on July 14, 2024. There was no documentation, in the record, indicating 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 and the March 25, 2024 plan of correction follow-up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation of a client prematurely leaving the facility, against medical advice during regular daytime business hours, is to be made known to the client's primary counselor and outreach as agree upon by the client to the emergency contact. During evening hours, a client leaving in such a manner is to be documented in the Monitors Communication Log and attempt made immediately after the client departs. This is to be accompanied by informing the APM or Executive Director. The outcome of the Monitor's attempt is to be conveyed via a note and or interoffice message to the former client's primary counselor for any further attempt to be made, and the required note made in the client's the chart. The current POC will include, creation of a form that will be copied and left for the primary counselor and APM, in the event that that counselor is not scheduled for work the following day, so that additional attempts can be made by the APM or another designated counselor, and the needed documentation added to the client's chart. This process addition has been sent to all relevant staff. The process was reviewed with the counseling staff by the Executive Director, and with the Monitoring staff by the APM. It will additionally be reviewed with all Monitoring staff during their monthly mandatory staff meeting on. Individuals responsible for this activity is completed are, Lead Monitor, APM, and Executive director. |
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 project 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 the project's fiscal 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 and the March 25, 2024 plan of correction follow-up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fiscal management services are provided to ACA by a management company. ACA communicates to them though the appointed Board Chair and Controller. All steps were taken by the ACA Executive Director, in communicating the licensure requirements to the Board Chair, with additional communications between the ACA APM and the Controller. The Board Chair informed the ACA Executive the Director approximately one month prior to the site inspection date that the management company had acquired a new auditing firm, but there was still the potential for the required audit to be produced in time. This did not occur, and an email stating this was received by the Board Chair, saying that the possibility of producing it wasalso affected nearing the end of the date required by the hurricane in Florida, where the management company resides.
The POC as able to be formulated by the ACA Director, given the administrative structure in-place, began with alerting the Board Chair of the current licensing status, and the significance of having the required information produced. The Board Chair stated that he would exert as much influence as possible within the management team given the circumstances in order to have the audit finalized and delivered. Therefore, the following steps will continue to be taken on behalf of ACA, by the Executive Director to aid in effecting a corrective outcome: Ongoing notifications and alerts, as to the time-frame required will be sent to the Board Chair and Controller. Weekly emails will be sent to the Board Chair and Controller requesting audit status updates. Correction Action date submitted, is chosen to aid in optimizing the potential to receive the needed fiscal information. To help reduce/eliminate the recurrence of any delay to the production of the financial information, The Executive Director will continue to advocate for the production of these document to begin at an earlier time. Without the change to accounting/auditing companies, it is therefore anticipated that this failure to meet the deadline for this data will be eliminated.
Individuals responsible for directly obtaining the fiscal data ,required for ACA are the Board Chair and Controller and secondarily, the ACA Executive Director. |
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 to ensure all hard copy client records were secured within locked storage containers.
At the time of the inspection, there was a pile of client-related documents unsecured and stacked on top of a shelving unit in the counselor's office, located in the basement of building # 440.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As part of the current POC the Executive Director met with the counselor utilizing the office in the basement of building #440, informing that individual of the current citation. The counselor was unaware that the papers not stored in a locked cabinet had contents other than blank forms. It was reiterated that all papers related to named clients must be accounted for a stored as required.
To further ensure that this would not reoccur, all counselors were informed of this requirement. To assist in reminding counselors ongoingly, a bold printed notice was provided to them to be placed in a position where it would be seen daily, that all such documents must be stored appropriately. This requirement will be reviewed in the next counselor meeting on the above stated date. |
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 seven of seven client records reviewed.
Client #1 was admitted on August 1, 2024 and was active at the time of inspection. There were release of information forms to a pharmacy, a laboratory and a government agency that were signed and dated by the client on August 1, 2024; however, the specific information to be disclosed was not included on any of the release forms.
Client #2 was admitted on August 1, 2024 and was active at the time of inspection. There were release of information forms to a pharmacy, a laboratory and a government agency that were signed and dated by the client on August 1, 2024; however, the specific information to be disclosed was not included on any of the release forms.
Client #3 was admitted on August 27, 2024 and was active at the time of inspection. There were release of information forms to a pharmacy, a laboratory and a government agency that were signed and dated by the client on August 27, 2024; however, the specific information to be disclosed was not included on any of the release forms.
Client #4 was admitted on June 26, 2024 and was discharged on July 14, 2024. There were release of information forms to a pharmacy, a laboratory and a government agency that were signed and dated by the client on June 27, 2024; however, the specific information to be disclosed was not included on any of the release forms.
Client #5 was admitted on July 11, 2024 and was discharged on September 20, 2024. There were release of information forms to a pharmacy, a laboratory and a government agency that were signed and dated by the client on July 11, 2024; however, the specific information to be disclosed was not included on any of the release forms.
Client #6 was admitted on May 14, 2024 and was discharged on July 19, 2024. There were release of information forms to a pharmacy, a laboratory and a government agency that were signed and dated by the client on May 14, 2024; however, the specific information to be disclosed was not included on any of the release forms.
Client #7 was admitted on May 30, 2024 and was discharged on July 5, 2024. There were release of information forms to a pharmacy, a laboratory and a government agency that were signed and dated by the client on May 30, 2024; however, the specific information to be disclosed was not included on any of the release forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Previously, the consent form had been changed to include the three purposes for which they are utilized, pharmacy, laboratory services, and government agencies. The POC included that the form have checkboxes next to each of the choices,(pharmacy, laboratory, government agency), to allow for specific designation at the time of utilization for a client.
Also, to further facilitate the proper use of the form it now states that the appropriate box for use must be checked. This was completed on the above date.
POC activities: The facility has corrected the deficiency by changing the form to allow for the designated recipient agency/type to be checked in a box. The facility has further added instructions for the person completing the form, re: using the checkbox. These changes also act to reduce/eliminate the potential for future errors. The new form was created on 11/01/2024. The clients present at the time of the inspection are no longer in treatment.
The current client files all reflecting the new form with one requiring to be re-signed by the client by the above date. Continued Monitoring will be performed by the APM.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of a discharge summary, in two of four applicable client records reviewed.
Client #4 was admitted on June 26, 2024 and was discharged on July 14, 2024. There was no discharge summary documented in the record at the time of inspection.
Client #7 was admitted on May 30, 2024 and was discharged on July 5, 2024. There was no discharge summary documented in the record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The POC is as follows: All ACA Counselors have received a checklist of all required documents to be held in the client charts.
Once a client time at the facility is ended, the completed chart must be given to the Director for final signature presence of the signed chart checklist. The APM will review then review the completed chart. Any deficiencies will be returned to the counselor for completion in no more than one business day. All charts of clients reviewed during the inspection process will be checked for any deficiencies. Any still existing will be corrected by the above date. Lastly, a meeting with the Executive Director, APM, and all counseling staff, is scheduled to review all requirements, including recent updates. To emphasize this, a review of the counseling staff job responsibilities, including documentation will be conducted on 11/13/2024. The parties responsible for review and integrity of the charts are the APM and Executive Director. |
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, personnel records, and a physical plant inspection, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for not following the written procedures for the management of treatment services, specifically the notification of 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 6, 2022 and October 17, 2023 annual licensing inspections and the March 25, 2024 plan of correction follow-up inspection. Failing to follow written procedures, specifically the notification of the emergency contact within 12 hours after a client is discharged from the facility against medical advice, was again found to be a deficiency in the October 7, 2024 annual licensing inspection.
A plan of correction for not completing an annual financial audit was submitted and approved by the Department for the October 6, 2022 and October 17, 2023 annual licensing inspections and the March 25, 2024 plan of correction follow-up inspection. Failing to complete an annual financial audit was again found to be a deficiency in the October 7, 2024 annual licensing inspection.
A plan of correction for ensuring all 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 and the March 25, 2024 plan of correction follow-up inspection. Failing to ensure all staff receive the communicable disease trainings was again found to be a deficiency in the October 7, 2024 annual licensing inspection.
A plan of correction for ensuring counselors received at least 25 hours of training annually was submitted and approved by the Department for the October 6, 2022 and October 17, 2023 annual licensing inspections. Failing to ensure counselors received at least 25 hours of training annually was again found to be a deficiency in the October 7, 2024 annual licensing inspection.
A plan of correction for ensuring all heaters were permanently mounted or installed was submitted and approved by the Department for the October 17, 2023 annual licensing inspection and the March 25, 2024 plan of correction follow-up inspection. Failing to ensure all heaters were permanently mounted or installed was submitted was again found to be a deficiency in the October 7, 2024 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of the next steps as stated for each current deficiency was performed. The measures deemed necessary to correct the previous attempts were found to require the following general adjustments which are specifically reflected in each response above. Therefore, the overarching changes which are to be implemented to further assure that the submitted plan of correction will be successful are as follows: Specific gaps in communication have been supported by enhanced written documentation. Failures to produce complete charting documentation has been further supported by checklists for direct service personnel and review by the Administrative Staff. Facility upkeep will also have enhanced oversight via shortened a time-frames for inspection and review, and again, direct oversight and review by the Administrative Staff. This will be aided by utilizing previous and current deficiency listings as guideposts and reminders for specific areas of focus, attention, and compliance. Follow-ups to assure staff requirements be met, will be implemented and checked by the appropriate administrative staff. Accountability between administrative staff is also included in these measures, including that between the Executive Director and APM and the Board Chair and Executive director.
These actions will serve to enhance general staff oversight and compliance through the implementation of increased documentation and communication, and lastly by the direct inspection of both the facility, and validation of required work production. |