INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alpha House, 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(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 one employee received the minimum of at least 6 hours of HIV/AIDS within the first two years of employment in one of one record.
Staff #1 was hired as project director on November 29, 2021 and is still employed at time of inspection. Staff #1 was due to have the communicable disease trainings no later than November 29, 2023. Staff #1 did not complete 6 hours of HIV/AIDS training until June 13, 2024.
The findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 13, 2023 annual licensing renewal inspection.
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Plan of Correction
Director of Operations will meet with new hired employees after one year of employment to go over their training record and identify the required trainings that still need to be completed. Director of Operations will meet with employees three months before the end of their first two years of employment to ensure that all required trainings have been completed or are registered to complete before their two year employment date. |
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 notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two applicable client record.
Client #5 was admitted to the inpatient level of care on January 12, 2024 and discharged on March 15, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The counselor on duty at the time of a resident discharge is responsible for notifying the client, in writing, of their decision to involuntarily terminate the client's treatment at the project. The client will recieve a copy and there will be a copy placed in the client's chart.
Director of Operations held an in-service training on June 19, 2024, to inform staff of this protocol and demonstrate how to complete the form in writing and make a copy for the client and for their chart.
Director of Operations will monitor discharges to ensure clients are receiving a copy of their discharge letter at time of discharge by confirming with staff that is conducting the discharge and will conduct monthly chart reviews to ensure that each discharged client has a completed discharge letter in their closed chart. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records and staff interview, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had an unusual incident occur on March 15, 2024 which involved physical assault by a client. The facility had not submitted a written unusual incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Director of Operations will create a binder for staff that includes instructions on how and when to inform the Department of unusual incidents within the required three days. Director of Operations will introduce this binder during staff meeting on July 31, 2024, and do an in-service training on how to complete reporting. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were developed with a client in five of seven records.
Client #3 was admitted to the inpatient level of care on March 12, 2024 and was active at the time of review. Client #3 had a master treatment plan completed on March 12, 2024. There was no indication that the client was involved in the development of the treatment plan.
Client #4 was admitted to the inpatient level of care on October 4, 2023 and was discharged February 14, 2024. Client #4 had a master treatment plan completed on October 4, 2023. There was no indication that the client was involved in the development of the treatment plan.
Client #5 was admitted to the inpatient level of care on January 12, 2024 and was discharged March 15, 2024. Client #5 had a master treatment plan completed on January 12, 2024. There was no indication that the client was involved in the development of the treatment plan.
Client #6 was admitted to the inpatient level of care on February 14, 2024 and was discharged April 22, 2024. Client #6 had a master treatment plan completed on February 14, 2024. There was no indication that the client was involved in the development of the treatment plan.
Client #7 was admitted to the inpatient level of care on February 8, 2024 and was discharged May 30, 2024. Client #7 had a master treatment plan completed on February 8, 2024. There was no indication that the client was involved in the development of the treatment plan.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Director of Operations conducted an in-service training with the counselors on June 19, 2024, to inform them that treatment plans must be completed with their clients present and the plan must be written in the client's words and once the treatment plan is completed the client may complete their signature on the document.
Director of Operations will monitor treatment plans monthly to ensure that treatment plans are collaborative, timely, and signed by the client. |