INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection was conducted on October 3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The facility failed to ensure that bathrooms were kept functional, clean and sanitary at all times. Based on the physical plant inspection conducted at approximately 1:00 pm, it was observed that every bathroom had cracked, chipped, or missing flooring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. maintenance staff will assess bathrooms the condition of the flooring and determine necessary repairs for each bathroom.
2. Maintenance staff will inform director of necessary repairs , cost of materials, and expected completion date for each bathroom
3. Maintenance staff will purchase materials to complete bathroom flooring repairs
4. Maintenance staff will repair bathroom flooring until each bathroom is completed. The director will monitor progress |
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
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures, for the year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The director signed the review form for the policy and procedure manual for this year 2019. The director will prepare, update the policy and procedure manual annually and sign the verification form |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to provide documentation verifying that the client was given written acknowledgement that they had been informed that the project may not discriminate in the provision of services on the basis of marital status in all client records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director revised the client rights form to include marital status. The revised form will be utilized and placed in client chart
The Director will include the revision on the client rights policy in the policy and procedure manual
Current clients will sign the updated client right form at the next individual session with Counselor 10/21/2019 |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
The facility failed to document in their medication policy and procedures, a particular policy and procedure regarding the control and accountability of drugs including who is authorized to remove the drug from the drug storage area.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1.The Director revised methods for Control and Accountability of Drugs Policy and procedure to include specific staff that may remove medication box from the medication cabinet, ( Clinical staff, monitor staff and administrative staff)
2. The Director will revise step 2 of this Policy and Procedure to include name of drug, dosage, time, date and initials of staff member.
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709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
The facility failed to develop procedures to follow regarding the documentation of unusual incidents.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Staff Member present during the unusual incident will notify the Director immediately
2. The staff member will contact the emergency contact identified, for the emergency contact consent of the unusual incident if the situation warrants the contact.
3. Staff member who was present will complete the ACA incident form within 8 hours.
4. The Director and staff member will complete the UIRF and forward to Ddap within 48 hours , to the extent permitted by state and federal confidentiality laws.
The Director will include the revised unusual incident policy and procedure manual. 10/21/2019 |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to develop procedures to follow regarding the prompt review and identification of the causes directly or indirectly responsible for unusual incidents.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Staff member present during the unusual incident will report to the Director , causes directly or indirectly responsible for the incident within 8 hours.
Staff member will complete the ACA incident form and UIRF form including direct and indirect causes of the incident, date , time location,, who was involved and outcome of the situation within 24 hours
the Director will include the revised unusual incident policy in the policy and procedures manual 10/21/2019 |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to develop procedures to follow regarding implementing of a timely and appropriate corrective action plan following an unusual incident.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The Director will develop a corrective action plan and will document this on the ACA incident form and also on the UIRF form within 48 hours
The Director will include the revised unusual incident policy in the policy and procedures manual 10/21/2019 |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to develop procedures to follow regarding the ongoing monitoring of the corrective action plan.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The Director will monitor the corrective action plan for on-going compliance on a monthly basis, if needed
The Director will include the revised unusual incident policy in the policy and procedures manual. 10/21/2019 |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to develop procedures to follow regarding the reporting mechanism that is to be used to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The Director will review client charts for consents regarding reporting on unusual incidents , i.e.,emergency contact, insurance co., probation, etc.
2. The Director will monitor information being reported for compliance with state and federal confidentiality laws.
The Director will include the revised unusual incident policy in the policy and procedures manual 10/21/2019 |