INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19-21, 2012, by staff from the Division of Drug and Alcohol 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 the review of personnel records, the facility failed to document that all staff completed at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in two of two personnel records.
The findings include:
Eight personnel records were reviewed on June 19-21, 2012. Two personnel records were reviewed for the completion of tuberculosis, sexually transmitted diseases and other health related topics training. The facility did not document the training in personnel records # 5 and 8.
Employee # 5 was hired on October 4, 2010 as a counselor. At least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum training was to be completed by October 4, 2011. The employee had 3 hours of sexually transmitted diseases documented. There was no documentation that the training was from an approved curriculum. There was no further documentation that the employee had completed the required hours of tuberculosis and other health related topics training.
Employee # 8 was hired on September 19, 2009 as a monitor. At least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum training was to be completed by September 19, 2011. There was no documentation that the training had been completed.
The project/facility director was interviewed on June 21, 2012 and confirmed the findings.
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Plan of Correction
Alpha House is tentatively scheduled to have a STD/TB training on site 9/14/12 by an approved DDAP trainer. This is mandatory for all staff, including #5 & #8 missing compliant documentation. Employee #5's corrected hours of training for STD/TB are being reprocessed by the training facility, Family Links, an approved curriculum provider at the time of training. Employee #8 will seek immediate training of STD/TB through BDAP Training Management System. In the event immediate training is unavailable for #8, on-site training is pending for 9/14/12 and/or the next available training from an approved curriculum trainer. All other staff will seek required trainings through the DDAP training management system to comply should the 9/14/12 training date not occur. To ensure staff receive the required training within the required timeframe Alpha House will require these trainings be completed during the first to six months of employment for their position. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure that cold food was kept at or below 40 degrees Fahrenheit and frozen food was kept at or below 0 degrees Fahrenheit.
The findings include:
The physical plant inspection was conducted on June 21, 2012 at approximately 1:20 PM. The facility had two refrigerators and six freezers available for use during the inspection. The internal thermometer in the upstairs refrigerator stated the temperature was 70 degrees Fahrenheit. The temperature was inspected a second time at 2:50 PM. The temperature was 65 degrees Fahrenheit. During the initial physical plant inspection, the temperature for freezer # 4 was 10 degrees Fahrenheit, # 5 was 18 degrees Fahrenheit, # 6 was 20 degrees Fahrenheit and # 7 was 10 degrees Fahrenheit. The temperature logs were reviewed and documented that the temperatures were consistently over 0 degrees Fahrenheit. The temperatures were inspected a second time at 2:50 PM. The temperatures remained the same in freezers # 4, 5, 6 and 7.
The Residential Manager was present during both inspections and confirmed the findings.
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Plan of Correction
The upstairs refrigerator is scheduled to have a seal replaced and it will be recharged with feron at that time. This will occur by July 15, 2012. Freezers #4,5,6, & 7 are also scheduled to be serviced and inspected by July 15, 2012. Should it be determined that any of the freezers are beyond repair, Alpha House will purchase an additional two freezers,for a total of 4 reasonably new freezers (2 freezers were purchased last year). The Residential Director is responsible for the oversight of this compliant plan |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the annual report, the facility failed to make an annual report available to the public within the time period stated in the project's policy manual.
The findings include:
The annual report for the 2010/2011 fiscal year was reviewed on June 19, 2012. The facility's fiscal year is July 1-June 30. Per policy, the annual report is to be completed within six months of the close of the fiscal year. The annual report was not made available to the public until March 12, 2012 as documented in a published newspaper advertisement.
The Project/ Facility Director was interviewed on June 19, 2012 and confirmed the findings.
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Plan of Correction
Should Alpha House not be granted an extention to the six month deadline for completion of the annual report, the agency will take every step necessary to insure that the annual report is completed within the six month deadline. The Executive Director is responsible for executing compliance by the end of the next fiscal year. |
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.
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Observations
Based on a review of administrative materials, the project failed to complete an annual audit of financial activities associated with the project's drug/alcohol abuse services per agency policy.
The findings include:
A review of the 2010/2011 audit was conducted on June 19, 2012. The project's fiscal year is July 1 through June 30. Per policy, the annual audit is to be completed within six months following the end of the fiscal year. The 2010/2011 audit was to be completed by December 31, 2011. The annual audit for the 2010/2011 fiscal year was completed on February 15, 2012.
The Project/Facility Director was interviewed on June 19, 2012 and confirmed the audit for the 2010/2011 fiscal year had been completed on February 15, 2012.
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Plan of Correction
Should Alpha House not be granted an extention to the six month deadline for completion of the audit, the agency will take every step necessary to insure that the audit is completed within the six month deadline. The Executive Director is responsible for executing compliance by the end of the next fiscal year. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of patient records, the facility failed to comply with the limitations imposed at 4 Pa. Code subsection 255.5 for information released to third party payers in six of six patient records
The findings include:
Twelve patient records were reviewed on June 19-21, 2012. Six patient records were reviewed for compliance with the confidentiality of client identity and records. The facility released information to third party payers that exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b) in patient records # 1, 2, 3, 4, 5 and 6. The facility released the drug of choice, age of 1st use, frequency of use, route of administration, number of previous treatments, number of arrests in past 24 months and whether they were DUIs, felonies or misdemeanors and whether or not the patient was involved in Narcotics Anonymous. The patient's legal issues, the name of the Judge and the name of the patient's probation officer were also released.
The Project/Facility Director was interviewed on June 21, 2012 and confirmed the findings.
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Plan of Correction
The information that was being distributed to the third party payers that exceeded the 4 Pa. Code subsection 255.5 will be removed from the document that the third party payer receives. Only that information on the 6 domains of the PCPC descripters for admission will be used to determine eligibility for payment under the PCPC 3C criteria. The Executive Director in conjuction with the Residential Director will be responsbile for the compliance. The compliance will be in effect on July 6, 2012. A memo will be sent to all staff notifying them of the change with a sample sheet. |
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 the review of patient records, the facility failed to notify the patient, in writing, of the reason for termination of services in one of two patient records.
The findings include:
Twelve patient records were reviewed on June 19-21, 2012. Six patient records reviewed were discharged patient records. Two discharged patient records had been terminated and required documentation of written notification of the decision to involuntarily terminate the client's treatment. The facility did not document the reason for the termination in patient record # 5.
Patient # 5 was admitted on December 16, 2011 and involuntarily discharged on March 26, 2012. The written termination letter did not document the reason the patient had been terminated.
The Residential Manager was interviewed on June 21, 2012 and confirmed the findings.
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Plan of Correction
Discharged client's termination notice will be changed to include a "Reason" with a few lines for counseling staff to write in greater detail the nature of the termination to them. The Residential Counselor will be responsible for writing the nature of the termination. The Residential Director with the approval of the Executive Director will be responsible for changing the format of the discharge notice to client's. This will be in compliance July 6, 2012. |
709.51(a)(2) LICENSURE Treatment Methodology
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
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Observations
Based on the review of patient records, the facility failed to provide to patients at least ten hours of services per week .
The findings included:
Twelve patient records were reviewed on June 19-21, 2012. Six patient records reviewed were inpatient records. Three were reviewed for documentation of at least ten hours of treatment services per week . The facility failed to document that patients were provided a minimum of ten hours per week of treatment services in patient records #1, 2 and 4. The patients record of service and progress notes documented less than ten hours a week of services.
The Project/Facility director was interviewed on June 21, 2012 and confirmed the documented findings.
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Plan of Correction
Alpha House counseling staff will document 10 hours of services per week, per client. The Residential Counselor's will be responsible for the documentation of the 10 hours of services provided per week. Alpha House will be in compliance with this standard July 9, 2012. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document treatment services as specified on the individual treatment plan for each client.
The findings include:
Twelve patient records were reviewed on June 19-21, 2012. Six patient records were reviewed as inpatient records. Three patient records were reviewed for documentation that treatment services were provided according to the individual treatment and rehabilitation plan. The facility failed to document individual counseling sessions with the frequency stated in the treatment plan in patient records # 1, 2 and 3.
Patient # 1 was admitted on February 1, 2012. The treatment plan completed on March 1, 2012 and subsequent updates documented the patient was to receive two hours per month of individual counseling. The patient received 30 minutes of individual counseling for the month of March; 1.75 hours for the month of April and 1.5 hours for the month of May, 2012.
Patient # 2 was admitted on August 15, 2011. The treatment plan completed on September 15, 2011 and subsequent updates, documented the patient was to receive two hours per month of individual counseling. The patient received 1.5 hours of individual counseling for the month of February; 1.75 hours for the month of March; .75 hours for the month of April and 0 hours for the month of May, 2012.
Patient # 3 was admitted on October 17, 2011. There was no treatment plan completed as of June 21, 2012. The patient had received only two individual counseling sessions since his admission, November 3, 2011 and February 17, 2012.
The project/facility director was interviewed on June 21, 2012 and confirmed the findings.
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Plan of Correction
The Residential Counselor responsible for developing the treatment plan in conjunction with the patient will abide by the hours the patient and counselor agree upon. Continuing compliance will be ensured by the Residential Director reviewing the individual patient file prior to the end of the month for compliance with treatment hours as indicated on the treatment plan. The Residential Counselor under the supervision of the Residential Director are responsible. Compliance will be achieved 7/31/12. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in three of three client records.
The finding include:
Twelve client records were reviewed on June 19-21, 2012. Six client records were reviewed as outpatient client records. The facility did not document that counseling services were provided according to the individual treatment and rehabilitation plan in client records # 7, 8 and 9.
Client # 7 was admitted on March 16, 2012. The individual treatment and rehabilitation plan, completed on April 14, 2012 stated that the client was to receive one individual counseling session per week. There were no individual counseling sessions documented for the weeks of April 2, 9, 16, 23 and June 11, 2012.
Client # 8 was admitted on January 4, 2012. The individual treatment and rehabilitation plan, completed on February 3, 2012 stated that the client was to receive one individual counseling session per week. There were no individual counseling sessions documented for the weeks of March 12, March 19, March 26, April 2, April 16, April 23, April 30, May 7, May 14, May 21, May 28, June 4 and June 11, 2012.
Client # 9 was admitted on February 21, 2012. The individual treatment and rehabilitation plan, completed on March 20, 2012 stated that the client was to receive one individual counseling session per week. There were no individual counseling sessions documented for the weeks of March 5, April 2, April 16, April 23, May 21, May 28 and June 11, 2012.
The Project/Facility Director was interviewed on June 21, 2012 and confirmed the findings.
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Plan of Correction
Alpha House will initiate documentation of the individual treatment and rehabilitation plan in client records #7,8, & 9 that reflect the reasons why this treatment plan goal was not attained, e.g. "The client failed to show or call for their scheduled session". A follow up call will be initiated to assertain the reason for the no show and/or reschedule. The Outpatient Director will be responsible for the documention in the client file. This will be in compliance July 9, 2012 (Outpatient Director currently on vacation). |