INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2014 and December 4, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel records reviewed.
The findings include:
Two personnel records of counselors requiring the documentation of the completion of 25 clock hours of annual training were reviewed on 12/3/2014. The facility failed to document the completion of 25 clock hours of annual training for employee #1.
Employee # 1 was hired on 10/1/1997 and promoted to a counselor on 4/4/2012. The facility's training year is from July through June. The training year for July 2013 to June 2014 was reviewed. Employee # 1 only completed 21 clock hours of annual training for the July 2013 to June 2014 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director has changed the annual training program to match that of the Pennsylvania Certification Board which is January 1st to December 31st. This policy change will begin January 1, 2015. The clinical supervisor will monitor trainings monthly to ensure that counselors are working towards 25 hours of training annually during quarterly staff meetings. Copies of all trainigs will be documented by clinical supervisor. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an observation during the physical plant inspection, the facility failed to ensure that the building grounds were free of hazards.
The findings include:
A physical plant inspection was conducted on 12/4/2014 at 10:20 AM. The lint trap in the Maytag Neptune dryer in the basement was covered with a layer of lint. This layer of lint presents a fire hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The House Manager Supervisor met with staff to explain the hazard level and the need to change the filter. The program director has added checking the filter to the daily rounds list and distributed to the staff. Weekly review of records to be completed by the house manager supervisor for the next 6 months then biweekling monitoring will take place. |
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 project failed to ensure that counseling services were provided according to the individual treatment plan in four of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services during the on-site inspection. The project failed to ensure that clients received counseling services according to the client's individual treatment plan in client records # 1, 5, 6 and 9.
Client # 1 was admitted to the facility on 9/30/2014. Client record # 1 contained a treatment plan dated 11/13/2014 that identified the counseling services to be provided as individual sessions once per day. The client's last individual session was conducted on 11/18/2014.
Client # 5 was admitted to the facility on 5/14/2014 and discharged on 9/15/2014. Client record # 5 contained a treatment plan dated 8/18/2014 that identified the counseling services to be provided as individual sessions once per week. The record did not contain documentation of any individual sessions during the week of 8/31/2014 - 9/6/2014.
Client # 6 was admitted to the facility on 6/23/2014 and discharged on 9/18/2014. Client record # 6 contained a treatment plan dated 9/8/2014 that identified the counseling services to be provided as individual sessions once per day. The client's only individual sessions conducted in September 2014 were on 9/9/2014 and 9/16/2014.
Client # 9 was admitted to the facility on 5/23/2014 and discharged on 8/1/2014. Client record # 9 contained a treatment plan dated 6/26/2014 that identified the counseling services to be provided as individual sessions once per week. The record did not contain documentation of any individual sessions during the week of 7/20/2014 - 7/26/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director has changed Master Treatment Plan Example to indicate the true services which is weekly individual sessions and met with clinical team at case review to update the information and ask that all old formats be destroyed. . The clincial supervisor will audit charts weekly for 6 months them monthly going forward for compliance. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in five of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 12/3/2014. The facility failed to document a complete record in client records # 2, 3, 4, 5 and 10.
Client # 2 was admitted to the facility on 10/10/2014. The record of service for the client did not include the individual counseling session that the client attended on 11/28/2014.
Client # 3 was admitted to the facility on 9/12/2014. The record of service for the client did not include the individual counseling session that the client attended on 11/19/2014.
Client # 4 was admitted to the facility on 5/22/2014 and discharged on 7/23/2014. The record of service for the client indicates that the client attended an individual counseling session on 7/21/2014. There was no documentation of a progress note for the individual counseling session conducted on 7/21/2014.
Client # 5 was admitted to the facility on 5/14/2014 and discharged on 9/15/2014. The record of service for the client did not include the individual counseling session that the client attended on 9/15/2014.
Client # 10 was admitted to the facility on 8/28/2014 and discharged on 11/5/2014. The record of service for the client did not include the individual counseling sessions that the client attended on 10/15/2014 and 10/27/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with clinical team at case review to reiterate the need for Record of Service and Progress Notes to be cohesive. The clincial supervisor will audit charts weekly for 6 months them monthly going forward for compliance. Charts identified in the audit as deficient will be updated to reflect the accurate and complete record of service. |