INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted June 5, 2024 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:
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Plan of Correction
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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.
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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 one of two employee records reviewed.
Employee #1 was hired on May 11, 2024 as the facility director and was still in the position as of the date of the inspection. There was no training plan documented.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 7, 2023 licensing inspection
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Plan of Correction
A training plan will be developed no later than 06/14/2024. The Director of Quality, Control, and Compliance will review the individual training plan on a monthly basis to ensure that it aligns with the required standards and that the training is completed within the specified timeframe. |
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.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training in the use of the fire extinguishers upon employment.
Employee #1 was hired May 11, 2024 for the position of facility director and was still employed at the time of the inspection. No training was documented in the employee record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 7, 2023 licensing inspection.
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Plan of Correction
Fire Extinguisher Training will be performed for all employees within 7 days of their employment, as required by reg 705.28. (d) (1). The Director of Quality Control and Compliance will conduct monthly reviews of staff files to verify adherence to regulations.
Facility Director has completed training.
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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.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training to perform assigned tasks during emergencies.
Employee #1 was hired May 11, 2024 for the position of facility director and was still employed in that position.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 7, 2023 licensing inspection.
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Plan of Correction
Emergency Training will be performed for all employees within 7 days of their employment, as required by reg 705.28. (d) (1). The Director of Quality Control and Compliance will conduct monthly reviews of staff files to verify adherence to regulations.
The Facility Director has successfully completed the emergency training plan, all staff members are in compliance.
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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.
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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 reviewed with facility staff during the licensing process.
This is a repeat citation from the November 7, 2023 licensing inspection
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Plan of Correction
The onsite draft manual has been replaced with an updated policy and procedure manual that includes signature. Project Director and Director of Quality, Control and Compliance will ensure annual review of the P&P manual and compliance of reg 709.23. |
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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of nine records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #1 was admitted on January 29, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 7, 2023 licensing inspection
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Plan of Correction
The Project Director and or the Director of Quality, Control & Compliance will discuss with the staff the policy on client confidentiality and DDAP rule 709.28.(c) in relation to the Consent to Release Information citation. The Project Director will continue to conduct random audits of client charts to ensure compliance. All identified deficiencies will be noted and addressed accordingly. |
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.
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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 four of four applicable discharged records reviewed.
Client #4 was admitted on June 6, 2023 and was discharged on May 1, 2024.
Client #5 was admitted on November 1, 2023 and was discharged on February 1, 2024.
Client #6 was admitted on January 7, 2024 and was discharged on January 30, 2024.
Client #7 was admitted on October 25, 2023 and was discharged on January 25, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 7, 2023 licensing inspection
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Plan of Correction
The project director will arrange a meeting with the project staff to discuss the significance of documentation and follow-up communication after discharge. The citation results, in addition to our internal policy and procedure, will be reviewed with the project staff. A mandatory self-audit will be conducted by the project staff to confirm the compliance of follow-up communication with any clients who have been recently discharged. The records of discharged clients will also be randomly audited by the Project Director to ensure compliance. |