INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Of SACA Drug And Alcohol Program 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
|
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an assessment of staff training needs.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of an assessment of staff training needs. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an overall plan for addressing these needs.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of an overall plan for addressing these needs. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of a mechanism to collect feedback on completed trainings.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of a mechanism to collect feedback on completed trainings This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in three of three employee records reviewed.
Employee #1 was hired on September 11, 2023 as the Project Director and was still in the position as of the date of the inspection. There was no training plan documented.
Employee #2 was hired on August 8, 2018 as a counselor and was still in the position as of the date of the inspection. There was no training plan documented.
Employe #3 was hired on February 20, 2023 as a counselor assistant and was still in the position as the time of the inspection. There was no training plan documented.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Individual training plans for the noted staff will be written and completed by the project director by 3/4/24.
The project director will audit employee files on a monthly basis to ensure that compliance remains. This will also begin on 3/4/24. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #2 was hired as a counselor on August 8, 2018 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2022 through December 31, 2022. Employee # 2's record only documented five hours and 30 minutes of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will ensure that employee #2 has the required amount of training hours by 3/4/24.
Project director will audit employee files on a monthly basis to ensure that compliance remains moving forward. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
Employee #2 was hired as a counselor on August 8, 2018 and was still acting in that position. Employee #2 was reported to have 40 hours per week devoted to their 48 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 40/40 = 1 (FTE); 48/1 = 48, which equals to a client counselor ratio of 48:1.
These findings were reviewed with facility staff during the licensing inspection
|
Plan of Correction
The project director will meet with employee #2 to ascertain his current caseload size. If current caseload is over 35, we will strategize which cases can be closed to ensure employee #2 does not have more than 35 cases. This will be completed by 3/4/23.
Project director will conduct a monthly audit of the number of active cases employee #2 has to ensure future compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #1 was hired on September 11, 2023 as the Project Director and was still in the position as of the date of the inspection. There was no training documented in the employee record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project manager will ensure that the noted employee completes fire extinguisher training by 3/4/24.
The project manager will audit employee files every month to ensure compliance moving forward. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #1 was hired on September 11, 2023 as the Project Director and was still in the position as of the date of the inspection. There was no training documented in the employee record at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The project manager will ensure that the noted employee completes training regarding their role in an emergency situation at the facility by 3/4/24.
The project manager will audit employee files every month to ensure compliance moving forward. |
709.22 (b) (3) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(3) Documenting the project ' s organizational structure.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document the project ' s organizational structure.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include an organizational structure of the project. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have the project director prepare, annually update and sign a written manual.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will ensure the policy and procedure manual is completed with signatures by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
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 the facility ' s policy and procedures manual, the facility failed to adopt a written procedures for the management of treatment/rehabilitation services for clients.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for procedures for managing treatment/rehabilitation services for clients. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt written procedures for referral outlining cooperation with other services providers including, but not limited to, provision for access to emergency services.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for referral outlining cooperation with other service providers, including, but not limited to, provision for access to emergency services. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures for utilization of volunteers.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for utilization of volunteers. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures for rules of conduct.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for rules of conduct. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of employee records, the facility failed to follow their policy regarding annual written individual staff performance evaluations being completed at 6 month and 12 months for employee #2.
Employee #2 was hired as a counselor on August 8, 2019 and was still in that role at the time of the inspection. Their employee record failed to contain documentation of an annual written individual staff performance evaluation.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedures manual to better reflect current staff performance evaluation practices, which is yearly. This will occur on 3/4/24.
If not already completed, the project director will ensure that the noted employees have current evaluations in their employee charts by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt written job descriptions for project positions.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include written job descriptions for project positions. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
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 must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on a review of the facility's policy and procedures manual, the facility failed to adopt a written procedures to address confidentiality of client identity and records. The policy and procedures did not include identification of the person responsible for maintenance of client records and procedures on keeping client records and identity confidential.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include written identification of the person responsible for the maintenance of client records and procedures for keeping client records and identity confidential. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.28 (a) (2) 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 must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written procedures for identification of project staff having access to records, and the methods by which staff gain access.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include written procedures for identifying project staff having access to records and the methods by which staff gain access. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.28 (c) 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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two out of ten records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #4 was admitted on August 16, 2023 and was discharged on November 1, 2023.
Client #9 was admitted on March 22, 2022 and was discharged on August 1, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will conduct a training with the counseling team to ensure proper documentation regarding consents. This will be completed by 3/4/23.
The project director will audit client charts randomly to ensure compliance. This will occur on a monthly basis.
|
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include a client receiving care or treatment under section 7 of the act (71 P.S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include client rights, especially those receiving care or treatment under section 7 of the act (71 P.S. 1690.107), shall retain civil rights and liberties except as provided by statute. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include client rights, including the project may not discriminate in providing services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to ensure clients have the right to inspect their records. The project, facility, or clinical director may temporarily remove portions of the records before the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for eliminating sections shall be documented in the record. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to appeal a decision limiting access to their records to the director.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include clients have the right to appeal a decision limiting access to their records to the director. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include that clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include that Clients have the right to submit rebuttal data or memoranda to their own records. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to accurately state the regulation in their manual, as their policy required physicians to provide written authentication to a verbal order within seven days. The regulation requires the written authentication to occur within 3 business days.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include that physicians must provide written authentication to a verbal order within three business days. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include physical assault or sexual assault by staff or a client.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include policies responding to unusual incidents, including physical assault or sexual assault by staff or a client. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include selling or use of illicit drugs on the premises.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include policies responding to unusual incidents, including the selling or use of illicit drugs on the premises. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include serious injury due to trauma, suicide, medication error or unusual circumstances.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents including serious injury due to trauma, suicide, medication error, or unusual circumstances. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to theft, burglary, break-in or similar incident at the facility.
These findings were discussed with facility staff during the inspection
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents to include theft, burglary, break-in or similar incident at the facility. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include event at the facility requiring the presence of policy, fire or ambulance personnel.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents and events at the facility requiring the presence of police, fire, or ambulance personnel. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include outbreak of a contagious disease requiring CDC notification.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents, including outbreaks of a contagious disease requiring CDC notification. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents, including prompt review and identifying the causes directly or indirectly responsible for the unusual incident. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include implementation of a timely and appropriate corrective action plan.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents and implementing a timely and appropriate corrective action plan. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include ongoing monitoring of the corrective action plan.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents and ongoing monitoring of the corrective action plan. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.91(a)(3) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(3) Requirements for completion of treatment.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes requirements for completion of treatment.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for intake and admission, including criteria for admission. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.91(a)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(4) Involuntary discharge/termination criteria.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes involuntary discharge/termination criteria.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for intake and admission, including criteria for involuntary discharge/termination. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in four out of ten applicable records.
Client #2 was admitted on June 6, 2023 and was still active at the time of the inspection.
Client #3 was admitted on June 1, 2023 and was still active at the time of the inspection.
Client #5 was admitted on August 8, 2023 and was discharge on September 27, 2023.
Client #6 was admitted on May 22, 2023 and was discharged on August 1, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will provide a training to the staff regarding fully completing psychosocial evaluations. A sign-in sheet will be provided to show proof of attendance and compliance. This training will occur by 3/4/24.
The project director will complete a monthly audit of charts to ensure compliance with this issue. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two of five applicable records reviewed.
Client #2 was admitted on June 6, 2023 and was still active at the time of the inspection. A treatment plan update was completed on June 28, 2023 and the next update was due no later than August 28, 2023; however, the next update was completed on October 16, 2023.
Client #9 was admitted on March 22, 2022 and discharged August 1, 2023. A treatment plan update was completed on March 6, 2023 and the next update was due no later than May 6, 2023; however, no update was completed in the record at the time of the inspection
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will provide a training to the staff regarding treatment plan update timeframes. A sign-in sheet will be provided to show proof of attendance and compliance. This training will occur by 3/4/24.
The project director will complete a monthly audit of charts to ensure compliance with treatment plan update dates. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of ten applicable records reviewed.
Client #2 was admitted on June 6, 2023 and was still active at the time of the inspection. The treatment plan dated June 28, 2023 indicated individual session weekly. There was no documentation that the client received individual sessions for August 2023 and September 2023.
Client #3 was admitted on June 1, 2023, and was still active at the time of the inspection. The treatment plan dated August 28, 2023 indicated weekly individual sessions. Based on a review of the record of services and progress notes the client received bi-weekly sessions starting September 1, 2023 until the time of the inspection.
Client #7 was admitted on March 10, 2023 and was discharged on August 7, 2023. The treatment plan dated March 24, 2023 indicated individual sessions weekly. There was no documentation that the client received individual therapy between April 11-25, 2023, May 30-June 13, 2023 and July 7-August 1, 2023.
Client #8 was admitted on February 7, 2023 and was discharged on May 20, 2023. The treatment plan dated March 2, 2023, indicated individual session weekly. There was no documentation that the client received individual therapy between March 16-May 1, 2023
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project held a training with all project staff regarding this issue on 11/14/23. A sign in sheet is available if you would like. This training addressed the issues which were audited.
The project director will audit files on a monthly basis to ensure that treatment services are aligned with the client's individual treatment plan. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in two of six applicable discharged records reviewed.
Client #5 was admitted on August 8, 2023 and was discharged on September 27, 2023.
Client #8 was admitted on February 7, 2023 and was discharged on May 20, 2023.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will review the need for aftercare services with project staff by 3/4/24. A sign-in sheet will be available to show proof of discussion.
Project director will audit discharged files on a monthly basis to ensure that compliance is current. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in four of seven applicable client records reviewed.
Client #4 was admitted on August 16, 2023 and was discharged on November 1, 2023.
Client #5 was admitted on August 8, 2023 and was discharged on September 27, 2023.
Client #6 was admitted on May 22, 2023 and was discharged on August 1, 2023.
Client #10 was admitted on June 15, 2023 and was discharged on August 29, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will meet with project staff to train them on the need for discharge summaries after a client discharges. A sign-in sheet will be available to show proof of meeting. This will occur by 3/4/24.
Project director will audit discharged charts on a monthly basis to ensure discharge summaries are present in the chart. |
709.93(a)(11) LICENSURE Client records
709.93. 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 provide a complete client record, which is to include follow-up information in six of six discharged records reviewed.
Client #5 was admitted on August 8, 2023 and was discharged on September 27, 2023
Client #6 was admitted on May 22, 2023 and was discharged on August 1, 2023.
Client #7 was admitted on October 6, 2020 and was discharged on May 19, 2023.
Client #8 was admitited on February 7, 2023 and was discharged on May 20, 2023
Client #9 was admitted on March 22, 2022 and was discharged on August 1, 2023.
Client #10 was admitted on June 15, 2023 and was discharged on August 29, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project director will update the policies and procedures to include documentation regarding follow-up timeframes. This will occur by 3/4/24.
Project director will meet with project staff to discuss importance of follow-up contact after discharge. This will also occur by 3/4/24.
Project director will audit discharged charts on a monthly basis to ensure compliance. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written client aftercare policy.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's aftercare policies. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written client follow-up policy.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's follow-up policies. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include identifying persons in need of project services.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's outreach service to identify persons needing project services. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include alerting persons and their families to the availability of project services.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's outreach service, including alerting persons and their families to the availability of project services. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include encouraging persons to utilize the service delivery system.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's outreach service, include encouraging persons to utilize the service delivery system. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |