INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on April 1, 2025 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director and facility director met the qualifications of the positions in one of one applicable personnel record reviewed
Employee #1 was hired as the project director and facility director on December 9, 2024 and was still in the position. At the time of the inspection, there was no qualifying educational degree documented in the personnel record; therefore, the employee did not meet the educational degree requirements for the position.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to the emergency termination of The former Facility Director the Administrative Program Manager was put in charge by the governing body
DDAP was contacted on 4/9/2025 and an exception was requested by the current Facility Director and the Board chairman of ACA. We submitted the request for the least amount of time to be approved which was 3 months
If the exception is not approved, the governing body will be notified and the clinical supervisor will assume the position.A job availability will be posted in the online employment sites by the administrative program manager . The Board of Directors will look over the resumes of who applied and schedule interviews. The Board Chairman will decide who to hire |
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 one of one applicable personnel record reviewed.
Employee # 2 was hired as a counselor on July 21, 2023 and was due to have a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training no later than July 21, 2024. The documentation in the personnel record indicated the employee only completed 5.25 hours of HIV/AIDS training and 1 hour of TB/STD training 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 renewal inspections, the March 25, 2024 plan of correction follow-up inspection and the October 7, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 2 was deficient in her mandatory trainings.
employee # 2 will complete the remaining necessary trainings by 4/25/25. She will submit to the Director the trainings that she signed up for to ensure that these will be done by 4/25/25.
the Director has created a form to document all staff trainings each time they complete them to ensure all trainings are completed during the training year and will be placed in their personnel files and reviewed monthly by the Director |
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.
At the time of the inspection, there was a window in the administrative office of building #438 that had two significant cracks in the glass.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the inspection it ws noticed, unbeknownst to the Director and staff that there were 2 small cracks in the office window of #438.
This was discussed with the maintenance person. Since we are a historic building the glass will have to be measured and special ordered. this will be completed by 6/30/25.
to ensure that our building is kept in good repair and safe the maintenance person will be required to do weekly checks for any damage to the property and submit a request for funds if needed |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in five of eleven client records reviewed.
Client # 1 was admitted on December 3, 2024 and was discharged on January 31, 2025. The release of information forms to a primary care physician and a medical provider were signed by the client on December 3, 2024; however, both forms did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 2 was admitted on December 23, 2024 and was discharged on January 9, 2025. The release of information forms to a primary care physician, a medical provider and another treatment provider were signed by the client on January 6, 2025; however, none of the forms included the name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted on January 28, 2025 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the client on January 28, 2025; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 5 was admitted on February 26, 2025 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the client on
February 26, 2025; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 11 was admitted on December 19, 2024 and was discharged on February 25, 2025. The release of information form to a medical provider was signed by the client on December 19, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
prior to this inspection new consent forms were created to ensure confidentiality and approved consent to relay information to an outside source.
the Director and clinical supervisor will require all client charts to be submitted for inspection on a weekly basis to ensure all consents have been thoroughly filled out, signed and the outside source was approved by the client. this will be started immediately on 4/16/2025 and continue every Wednesday |
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 client records, the facility failed to document the purpose of the disclosure on release of information forms in five of eleven client records reviewed.
Client # 1 was admitted on December 3, 2024 and was discharged on January 31, 2025. The release of information form to another treatment provider was signed by the client on December 3, 2024, but there was no purpose of the disclosure included on the consent form.
Client # 3 was admitted on January 28, 2025 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the client on January 28, 2025, but there was no purpose of the disclosure included on the consent form.
Client # 5 was admitted on February 26, 2025 and was still active at the time of the inspection. The release of information forms to other treatment providers were signed by the client on February 26, 2025, but there was no purpose of the disclosure included on the consent form.
Client # 8 was admitted on February 18, 2025 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the client on February 18, 2025, but there was no purpose of the disclosure included on the consent form.
Client # 9 was admitted on December 5, 2024 and was discharged on January 9, 2025. The release of information form to another treatment provider was signed by the client on December 5, 2024, but there was no purpose of the disclosure included on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
prior to this inspection revised consent forms were created for a space for the outside provider name and a check list ( to manually check off) of information that the outside provider is requesting and being sent to that source.
Staff will be informed that all consent forms must thoroughly be filled out with the name of the outside provider/source and the information requested from the outside source and discussed with clients so as they are consenting to this information being sent. Only then will they be able to sign the consent. this will be addressed and the POC will be done by 4/15/2025 |
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 ensuring all staff received the HIV/AIDS training and the TB/STD training within the regulatory timeframe was submitted and approved by the Department for the October 1, 2021, October 6, 2022, October 17, 2023, and October 7, 2024 annual licensing renewal inspections and the March 25, 2024 plan of correction follow-up inspection. Failing to ensure all staff received the communicable disease trainings was again found to be a deficiency in the April 1, 2025 provisional follow-up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
the failure to follow the POC from last survey was result from an oversight and failure from the coordination between the Director and the APM
POC: The Director will discuss POC's with all employees to ensure that they are aware of what is required, changes needed, what is being corrected and have an understanding of the importance of adhering to the POC |