INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6 through 7, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on February 1, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of the staffing self report form completed by the agency and employee records during the annual onsite licensing inspection of January 6 and 7, 2010, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
During the annual onsite licensing inspection the employee records of two clinical staff were reviewed. The facility failed to ensure the staffing ratio remained at or under 35:1.
Employee # 1 had at 43:1 ratio.
This is a repeat deficiency. The facility was previously cited at the conclusion of the December 19, 2008 drug and alcohol licensing inspection.
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Plan of Correction
Employee #1 in the process of reducing client ratio to or under 35:1. Target date is February 5,2010.
Project director will receive weekly reports of client ratios and ensure that these ratios remain at or under 35:1 |
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 employee personnel records the facility failed to instruct staff in the use of the fire extinguisher upon staff employment.
The findings include:
Based on the review of employee personnel records on January 6, 2010 the facility failed to ensure that fire extinguisher training was conducted within seven days of hire for employee # 2.
Employee # 2 was hired on 12/22/2009. To date the facility failed to document fire extinguisher training for this employee.
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Plan of Correction
All clinic staff received fire extinguisher training on January 19, 2010 including employee #2. Signed verification was placed in each employee's personnel record.
In the future Project Director will ensure that fire extinguisher training will be held on 1st day of orientation of any new staff and documented and placed in employee record. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review administrative fire drill logs, the facility failed to use alternate exit routes during fire drills.
The findings include:
Based on the review of administrative fire drill logs on January 6, 2010, the facility failed to document exit routes utilized for evacuation for the last twelve months.
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Plan of Correction
New fire drill log was developed that documents exit routes during and shown to Inspector on January 6,2010. New fire drill log now in utilization. Administrative supervisor will show log to Project Director who will initial after each fire drill. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review administrative fire drill logs, the facility failed to conduct fire drills on different days of the week at different times of the day.
The findings include:
Based on the review administrative fire drill logs on January 6, 2010, the facility failed to conduct fire drills on different days of the week at different times of the day. The facility conducted their fire drills at 10:00 a.m. for the past twelve months and conducted them on a Thursday for ten out of twelve months this last year. The drills were conducted on Thursday for the months of January 09, February 09, March 09, April 09, May 09, June 09, July 09, August 09, September 09, and October 09.
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Plan of Correction
New fire drill schedule was developed that conducts fire drills on different days of the week at different times of the day and shown to Inspector on January 6, 2010. New schedule now in utilization. Administrative supervisor will show fire drill log to Project Director who will review and initial after each fire drill |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of the facility fire drill logs, the facility failed to document that they set off a fire alarm or smoke detector during each fire drill.
The findings include:
Based on a review of the facility fire drill log on January 6, 2010, the facility failed to document whether or not the alarm was activated for fire drills during the past twelve months.
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Plan of Correction
New fire drill log was developed and shown to the Inspector on January 6, 2010 and now is in utilization. New fire drill log documents the activation of fire alarm or smoke detector during each fire drill.
Administrative supervisor will show Project Director fire drill log after each fire drill to ensure proper documentation. Project director will initial as verification. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2008 annual report and an interview with the project director, the governing body failed to make available to the public the 2008 annual report.
The findings include:
The 2008 annual report was reviewed on January 4, 2010. The facility is publicly funded and required to make an annual report available to the public. The 2008 fiscal year ended on June 30, 2009.
In an interview with the project director stated on January 5, 2010 it was stated that the annual report would be available online. The governing body failed to make the 2008 annual report available to the public, as of January 8, 2010.
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Plan of Correction
The annual report was uplinked to the agency website on January 15, 2010 and is available for viewing by the public.
In the future the Project Director will remind the corporate to make this information available in a timely fashion
The annual report for fiscal year 2009-2010 will be posted after the end of the fiscal year June 30,2010. Target date for posting for public viewing is July 9, 2010. Project director will remind agency CEO of importance of posting prior to target date and check website to ensure posting by or before target date. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative documentation the project failed to document that the governing body was presented the policy and procedure manual on an annual basis.
The findings include:
Facility administrative records were reviewed on January 7, 2010. The facility had no documentation that the policy and procedure manual was presented to the governing body for the 09-10 fiscal year.
This is a repeat deficiency. The facility was previously cited at the conclusion of the December 16-17, 2008 licensing inspection.
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Plan of Correction
Project director presented governing board with policies and procedures manual on January 27, 2010 and board chair signed verification.
In the future Project diirector will present policies and procedures manual
to governing board for review and verification at the first board meeting of the each new fiscal year. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation and an interview with the project/facility director the facility failed to present the goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 to the governing body. Additionally, the facility failed to include time frames and available resources.
The findings were:
Based on a review of administrative documents on January 7, 2010 it was determined that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 were not presented to the governing body. Additionally the goals and objectives that were in place, failed to indicate time frames and available resources.
The facility was previously cited at the conclusion of the December 16-17, 2008 drug and alcohol licensing inspection for not presenting the goals and objectives to the governing body.
An interview with the project/facility director on January 7, 2010 confirmed that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 had not been provided to the governing body.
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Plan of Correction
Project director presented board of directors with goals and objectives for fiscal year 2009-2010 along with a mid-year update/evaluation on January 27, 2010 and board chair signed off on verification.
In the future project director will develop with agency CEO annual goals and objectives in a format that includes specific time frames and available resources and present to governing board at first board meeting of each new fiscal year for verification. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in nine of nine client records.
The findings include:
Ten client records were reviewed on January 6-7, 2010. Psychosocial evaluations were required in nine client records. The facility failed to document psychosocial evaluations in client records # 1,3,4,5, and 6. The facility failed to have complete psychosocial evaluations in client records # 2, 7, 8 and 10.
Client record # 2 psychosocial evaluation failed to include the client's composite picture, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client record #7 psychosocial evaluation failed to include the client's problems/ needs, assets/strengths, support systems, and coping mechanisms.
Client record # 8 psychosocial evaluation failed to include the client's assets/strengths, support systems, and negative factors.
Client record #10 psychosocial evaluation failed to include the client's composite picture, assets/strengths, coping mechanisms, and attitude towards treatment.
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Plan of Correction
A new psychosocial evaluation that includes a complete client's composite picture, assets/strengths, problems/needs, support system,coping mechanisms, negative factors, and attitude toward treatment was shown to Inspector at time of visit and implemented immediately.
Project director will inspect all new charts to ensure that the new psychosocial evaluation is included and review psychosocial evaluation at weekly case review to ensure that it is completed in full. |