INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 21, 2012 licensure renewal inspection. The follow-up inspection was conducted on December 4, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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 treatment services per week in four of four patient records .
The findings included:
Nine patient records were reviewed on December 4, 2012. Five patient records reviewed were inpatient records. Four patient records 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, 3 and 4. The patient record of service and progress notes documented less than ten hours a week of treatment services.
The project/facility director and clinical supervisor were interviewed on December 4, 2012 and did not dispute the findings.
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Plan of Correction
Alpha House has increased the length of time for providing group therapy three times per week from two hours to three hours Monday, Wednesday, Friday. Each counselor is providing individual therapy to their assigned resident on a weekly basis. The Residential Counselor is responsible for the documentation, the Residential Director is responsible for insuring that this occurs. This plan of correction was instituted December 17, 2012. |
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:
Nine client records were reviewed on December 4, 2012. Four client records were reviewed as outpatient client records. Three client records were reviewed for documentation that counseling services were provided according to the individual treatment and rehabilitation plan. 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 October 2, 2012. The individual treatment and rehabilitation plan, completed on October 23, 2012 did not include documentation of the type and frequency of treatment services. It was not possible to determine if the client was receiving counseling services according to the individual treatment and rehabilitation plan.
Client # 8 was admitted on June 12, 2012. The individual treatment and rehabilitation plan, completed on July 11, 2012 and the individual treatment and rehabilitation plan updates indicated that the client was to receive one individual counseling session per week. The client had one individual counseling session, August 21, 2012, documented for the month of August. The client had two individual counseling sessions, September 13 and 26, 2012, documented for the month of September. The client had two individual counseling sessions, October 11 and 25, 2012, documented for the month of October. The client had one individual counseling session, November 27, 2012, documented for the month of November.
The project/facility director was interviewed on December 4, 2012 and did not dispute the findings.
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Plan of Correction
The Outpatient Director will include the type and frequency of treatment services on each individual treatment plan. When weekly sessions are indicated, the Outpt. Director will document absenteeism and initiate a follow up phone call in an to attempt to comply with the type and frequency requirements of the treatment plan. This will be evidenced in the individual client file. The Outpatient Director is responsible for the documentation and the Executive Director will supervise. This plan of correction has been implemented on December 17, 2012. |