INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 12, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPANISH AMERICAN CIVIC ASSOCIATION FOR EQUALITY, 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:
|
Plan of Correction
|
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill logs from January, 2025 - December, 2025 the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of fire drills occurring during the months of October or November, 2025.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
This program was temporarily closed on 12/15/2025. Upon reopening, updated policies and procedures will be reviewed with newly hired staff. Fire drill reports will be required to be submitted to the Quality Director within 24 hours of each drill to ensure compliance with regulatory requirements. |
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.
|
Observations
Based on a review of client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice in two out of two applicable records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
SACA placed its SUD programs on a 90-day internal Corrective Action Plan (CAP) after identifying operational deficiencies. The CAP was implemented from September 2025 through December 2025. Staff who failed to comply with proper discharge and documentation requirements were placed on Performance Improvement Plans (PIPs), this occurred in the month of November 2025. Additionally, the Policy and Procedure Manual was reviewed with staff at this location by the then?Project Director.
Currently the program is temporarily closed since 12/15/2025 however upon reopening the Quality Director will conduct weekly audits of all AMA discharges for 60 days, then monthly thereafter, to ensure compliance with the notification requirement.
Audit results will be shared with the SUD Director and leadership team.
Corrective Oversight and Accountability:
Any instance of non-compliance will result in immediate review and corrective action, including staff re-education and potential disciplinary action if warranted.
The SUD Director will be responsible for addressing staff performance issues and reinforcing expectations. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #3 was admitted on July 2, 2025 and was discharged on September 13, 2025. A treatment plan was completed on July 15, 2025 and an update was due no later than August 15, 2025. However, it was not completed until August 20, 2025.
Client #4 was admitted on June 10, 2025 and was discharged on July 23, 2025. A treatment plan was completed on June 11, 2025 and an update was due no later than July 11, 2025. However, none was completed.
Client #5 was admitted on May 22, 2025 and was discharged on August 22, 2025. A treatment plan was completed on June 13, 2025 and an update was due no later than July 13, 2025. However, none was completed.
Client #7 was admitted on October 28, 2025 and was discharged on December 12, 2025. A treatment plan was completed on November 4, 2025 and an update was due no later than December 4, 2025. However, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
SACA placed its SUD programs on a 90-day internal Corrective Action Plan (CAP) from September 2025 through December 2025 after the Quality Director identified ongoing documentation deficiencies. Staff who failed to comply with documentation requirements, including updating treatment plans in accordance with SACA's SUD Program Manual, were placed on Performance Improvement Plans (PIPs). During this time, the Policy and Procedure Manual was reviewed with staff at this location by the Project Director.
Although the program is currently temporarily closed, upon reopening, the Quality Director will continue conducting random chart audits to mitigate documentation issues. Additionally, all new clinical staff will be required to review the Policy and Procedure Manual and provide signed acknowledgment of completion. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven records reviewed. The facility's policy and procedures manual states that case consultations must be completed at time of the treatment plan update.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
SACA placed its SUD programs on a 90-day internal Corrective Action Plan (CAP) from September 2025 through December 2025 after the Quality Director identified ongoing operational and documentation deficiencies. Staff responsible for daily operations and clinical care who did not comply with SACA's SUD program manual were placed on Performance Improvement Plans (PIPs).
Although the program is currently temporarily closed, upon reopening all newly hired staff will be required to review the policy and procedure manual and provide signed acknowledgment. Failure to comply with the manual may result in placement on a PIP and could lead to termination. The Quality Director will continue to audit the program on a monthly basis. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed within seven days and 30 days following discharge.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The policy and procedure related to regulation 709.53(a)(11) have been revised to clarify that the additional 30-day follow-up applies only to clients enrolled in the specific required MCO that mandates this extra follow-up. Although the program is currently temporarily closed, all newly hired staff will review and sign off on the updated Policy and Procedure Manual upon reopening.
The Quality Director will continue conducting monthly random chart audits to mitigate documentation issues. Any instance of non-compliance will result in immediate review and corrective action, including staff re-education and potential disciplinary action if warranted. The SUD Director will be responsible for addressing staff performance issues and reinforcing expectations. |