INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 23, 2010 through August 24, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on September 25, 2010.
|
Plan of Correction
|
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative materials and staff interview, the facility failed to complete an audit within six months of the end of the project's fiscal year.
The findings include:
A licensing inspection was conducted on August 23, 2010 through August 24, 2010. The audit presented for review on August 23, 2010 was for the project's fiscal year ending June 30, 2009. The audit was completed on May 11, 2010, which is eleven months after the end of the fiscal year. The project director and the governing body president stated they had obtained a new accountant and the audit was not able to be completed within six months of the end of the fiscal year.
|
Plan of Correction
ACA Audit will be completed as the state regulation requires. ACA has retained a new accounting firm with the agreement that the audit will be conducted to meet the state reguation time frame. Executive Director will monitor this so the deficiency does not recur. Corretion has been made. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill records and staff interview, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
Fire drills records were reviewed on August 23, 2010. Fire drills were reviewed from September 2009 through August 2010. There was no documentation to show that a fire drill was conducted during the facility's sleeping hours of 11:30 PM to 7:00 AM from September 2009 to August 2010. The last documented fire drill conducted during the facility sleeping hours occurred on June 10, 2009 at 2:35 AM. A discussion with the administrative assistant and maintenance man was unable to verify whether a fire drill had been conducted during the facility sleeping hours since the drill dated June 10, 2009 because some of the documented times of the fire drills did not specify whether it was an AM drill or a PM drill.
|
Plan of Correction
Fire drill log format has been modified to include compliance of two overnight drills within six month time. The Executive Director is responsible for monitoring this compliance. New format is complete and effective immediately. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on a review of client records, the facility's policy and procedure manual and staff interview, the facility failed to collect a medical history as part of the intake procedures in six of six client records.
The findings include:
The facility's policy and procedure manual was reviewed on August 23, 2010 and August 24, 2010. The facility's policy on treatment/rehabilitation management states: "As part of the admission process the intake counselor or designated staff member will complete the Psychosocial History part 1, which shall include the following: A medical history that includes the client's personal and family medical histories, history of illness and symptoms and previous hospitalizations."
Six client records were reviewed on August 24, 2010. Six client records required a medical history to be collected by the facility as part of the client's intake. The medical histories included in client records #1, 2, 3, 4, 5 and 6 were collected by the referral source rather than by the facility completing the intake and admitting the client. During a discussion with the project director, it was confirmed that the facility does not collect it's own medical history on clients during intake. The project director noted they incorporate the referral source's medical history into their own psychosocial assessment.
|
Plan of Correction
BPS will be modified to require staff to both acknowledge, by referrence, prior medical history as well as incorporating our own medical history. Executive Director assumes responsibility, corretion will be made within 30 days. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility's policy and procedure manual and staff interview, the facility failed to document a preliminary treatment plan within the time frame stated in the facility's written policy in five of six client records.
The findings include:
Six client records were reviewed on August 24, 2010. A preliminary treatment plan was required in six client records. The facility policy states the preliminary treatment plan is to be completed within one day of admission. The preliminary treatment plan was completed late in five of six client records.
Client #1 was admitted was on 6/4/10. The preliminary treatment plan in client record #1 was dated 6/10/10.
Client #3 was admitted was on 6/1/10. The preliminary treatment plan in client record #3 was dated 6/03/10.
Client #4 was admitted was on 4/01/10. The preliminary treatment plan in client record #4 was dated 4/05/10.
Client #5 was admitted was on 2/1910. The preliminary treatment plan in client record #5 was dated 2/22/10.
Client #6 was admitted was on 5/7/10. The preliminary treatment plan in client record #6 was dated 5/14/10.
|
Plan of Correction
ACA written Policy has been changed to reflect new time system of completing a preliminary treatment plan. New policy states, Preliminary treatment plans are to be completed within 7 days of admission. Executive Director assumes responsibility. Corretion has been made. |