INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20-21, 2022 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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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on a review of unusual incident reports, the facility failed to provide staff coverage 24 hours a day.
An incident report dated November 11, 2021 documented the overnight staff person abandoned their shift in the middle of the night, leaving the facility without staff until 9 AM the next morning.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
The Director of Operations is responsible for ensuring that Alpha House, Inc has staff coverage 24 hours a day.
The Lead Counselor is responsible for making the staff schedule to ensure that Alpha House, Inc has staff coverage 24 hours a day.
On November 11, 2021, a staff member abandoned his shift during the night, leaving the facility for some time without 24 hour coverage.
I will propose a 24/7 on-call system for staff to use in the event that he or she is going to abandon their shift. When a staff member decides that he or she cannot complete their shift, and that staff member is the only staff member on site, he or she will call the staff member on-call, so that the called upon staff member will come to relieve the staff member who needs to leave.
A new form has been added to the new hire paperwork. This new form will be given and signed by all current staff and added to their Personnel file. This form is notification that if he or she decides to abandon their shift and there is no other staff on site, then the protocol to be followed is to call the on-call staff member and wait to be relieved. The reason for abandoning a shift will be evaluated by the Director of Operations, thereafter.
The on-call system will be a rotation of three clinical staff members per week, to be assigned one week in advance.
The new form titled, "Staff Coverage 24 Hours a Day", will include the protocol that needs to be followed. This new form was created today and will take one week for all current staff to sign and be notified of the 24/7 on-call system rotation.
Date of Compliance is 08/08/2022 |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to contact the client's emergency contact when the client left against medical advice (AMA) discharge, as stated in facility policy in one of one client records.
Client # 6 was admitted on October 28, 2021 and was discharged February 18, 2022. There was no documentation of the emergency contact being notified in client record. #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Counselor for the client who leaves against medical advice (AMA) is responsible for contacting the client's emergency contact and completing documentation for this call.
The Lead Counselor will be responsible for reviewing each client's discharge. If the discharge was against medical advice (AMA), then the Lead Counselor will ensure that there is documentation in the client's chart for the emergency contact call upon discharge.
If there is no documentation, then the Lead Counselor will contact the Primary Counselor and ensure that the emergency contact is called and documentation is completed.
On August 3rd, 2022, The Director of Operations will meet with the Lead Counselor and Primary Counselors to inform them of this protocol moving forward. Primary Counselors and Lead Counselor will sign a form of acknowledgment, stating their commitment to this protocol.
Date of compliance is 08/03/2022 |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on the signed consent to release information in two of seven client records.
Client #5 was admitted on September 23, 2021 and discharged on May 15, 2022. A release of information signed by the client on April 26, 2022 did not have any documentation of specific information to be disclosed.
Client #6 was admitted on October 28, 2021 and discharged on February 18, 2022. A release of information signed by the client on November 11, 2021 had "N/A" written for the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counselor who completes a consent form with a client is responsible for documenting the information to be disclosed on the signed consent form.
The Director of Operations will meet with Counselors on August 3rd, 2022, to demonstrate how to properly document the information to be disclosed on a consent form that will be signed by a client. Specific examples will be given for incorrect and correct ways to document the information to be disclosed.
The Director of Operations will notify the Lead Counselor and Counselors of the following on 08/03/2022: When Counselors complete consent forms with clients, then the form will be submitted to the Lead Counselor for review before the form is filed in the client's chart.
Date of compliance: 08/03/2022 |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on the signed consent to release information in five of seven client records.
Client #1 was admitted on June 29, 2022 and is currently an active client. Two releases of information signed on June 29, 2022 did not include the purpose of disclosure. One was blank and one had "5 point information" listed as the purpose.
Client #2 was admitted on June 3, 2022 and is currently an active client. One release of information was signed on June 13, 2022 and had "check" written as a purpose. One release of information signed on June 4, 2022 had "General Information" written as the purpose.
Client #3 was admitted on June 6, 2022 and is currently an active client. Two releases of information dated June 6, 2022 did not include a purpose. One release was blank and the other listed "Treatment Progress" as the purpose.
Client #4 was admitted on September 27, 2021 and discharged on April 20, 2022. Two releases of information dated September 27, 2021 did not include a purpose. One was blank and the other listed "Treatment Progress".
Client #5 was admitted on September 23, 2021 and discharged on May 15, 2022. A release of information signed by the client on September 24, 2021 did not include a purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counselor who completes a consent form with a client is responsible for documenting the purpose of disclosure on the signed consent form.
The Director of Operations will meet with Counselors on August 3rd, 2022, to demonstrate how to properly document the purpose of disclosure on a consent form that will be signed by a client. Specific examples will be given for incorrect and correct ways to document the purpose of disclosure.
The Director of Operations will notify the Lead Counselor and Counselors of the following on 08/03/2022: When Counselors complete consent forms with clients, then the form will be submitted to the Lead Counselor for review before the form is filed in the client's chart.
Date of compliance: 08/03/2022 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document a copy of the consent was offered to the client in one of seven client records.
Client #1 was admitted on June 29, 2022 and is currently an active client. One release signed June 29, 2022 did not include documentation that a client was offered a copy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Counselor is responsible for completing consent forms with clients.
All consent forms need to document that a copy of the consent was offered to the client.
The Director of Operations is responsible for ensuring that all consent forms provide documentation that a copy of the consent was offered to the client. The Director of Operations will review all consent forms and consent form templates by 08/03/2022, to ensure that the forms provide documentation that a copy of the consent was offered.
The Director of Operations will address Primary Counselors in a staff meeting on 08/03/2022, and present the consent forms that provide documentation to be completed that evidences that the client was offered a copy, and demonstrate proper documentation.
Staff will sign to acknowledge this teaching.
Compliance date is 08/03/2022. |