INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Nuestra Clinica of SACA Drug and Alcohol Program by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, December 4, 2013 was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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, the facility failed to document the instruction of staff in the use of the fire extinguisher in one of four personnel records.
The findings include:
Four personnel records were reviewed on December 4, 2013. One personnel record was required to document fire extinguisher training. The facility failed to document the completion of fire extinguisher training within seven days of staff employment in personnel records # 4.
Employee # 4 was hired on April 14, 2013. The training was due within seven days, by April 21, 2013. The training was not documented as of the date of the licensing inspection.
An interview with the project/facility director on December 4, 2013 confirmed the findings.
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Plan of Correction
The project director will be responsible for training new hires on the fire extinguisher training going forward. This training will be documented and placed in the employee file. For employee record #4, the project director trained the employee and placed the copy of training in the employee file. |
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, the facility failed to document the instruction of staff in emergencies in one of four personnel records.
The findings include:
Four personnel records were reviewed on December 4, 2013. One personnel record was required to document emergency training. The facility failed to document the completion of the emergency training within seven days of staff employment in personnel records # 4.
Employee # 4 was hired on April 14, 2013. The training was due within seven days, by April 21, 2013. The training was not documented as of the date of the licensing inspection.
An interview with the project/facility director on December 4, 2013 confirmed the findings.
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Plan of Correction
The project director will be responsible for training new hires on the disaster training going forward. This training will be documented and placed in the employee file. For employee record #4, the project director trained the employee on disaster procedures and placed the copy of training in the employee file |
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 of the facilities fire drill record, the facility failed to document alternate exit routes used during the fire drills.
Findings:
The fire drill record was reviewed on December 3, 2013. The months reviewed were January 2013 - October 2013. 7 of the 10 months documented front/rear exits used, 1 months documented front/senior center/rear exits used and 1 month front exit used.
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Plan of Correction
The project director will assume the task of making sure that alternate exits are used during drills. Each month an exit will be blocked to assure the that staff are aware of how to exit the building from any area.
This began with the December fire drill on Friday, December 13, 2013. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a reviewed of client records the facility did not document a medical history in three of six client records.
The findings include:
Ten client records were reviewed on December 4, 2013. Six of the ten were reviewed for medical histories,#1,2, 3, 4, 5 and 6. The six client records failed to include documentation of the family's medical history with symptoms and illnesses.
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Plan of Correction
The clinical supervisor and project director sat with staff and re-trained on how to document family vs. client medical history. The clinical supervisor will perform random chart audits weekly to ensure compliance. |
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 provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in four of six records reviewed.
The findings include:
Ten client records were reviewed on December 4, 2013 A psychosocial evaluation was reviewed in six client records, #1, 2, 3, 4, 5 and 6.
The psychosocial evaluations in client records #3, 4, 5 and 6 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #3, 4, 5 and 6 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records #3, 4, 5 and 6 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #4, 5 and 6 did not include an evaluation of the negative factors of the client.
The psychosocial evaluations in client records #4 did not include an evaluation of the counselor conclusions/impressions of the client.
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Plan of Correction
The clinical supervisor and project director sat with staff and re-trained on how to elaborate on theclient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions. The clinical supervisor will perform random chart audits weekly to ensure compliance |
709.93(a) 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:
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Observations
Based on a review of client records on December 4, 2013, the facility failed to have a complete record in four of seven records reviewed.
The findings include:
Seven of the ten client records were reviewed for discharge summaries, #1, 6, 7, 8, 9 and 10. The discharge summaries failed to include the client reason for treatment , #8, 9 and 10. Client #6 was discharged on March 11, 2013. As of the date of the licensing inspection client, #6's discharge summary was not documented. Also, client record #9 had a discharge summary documented but did not have a date when it was completed and client record #10 discharge summary was completed on June 25, 2013 but the client was not discharged until June 30, 2013.
Additionally, client #8 was discharge successfully on July 1, 2013 and their record did not document an aftercare plan. Also, client # 10 was discharged on June 30, 2013 and as of the date of the licensing inspection there was no documentation of a follow-up.
An interview with the project/facility director on December 4, 2013 confirmed the findings.
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Plan of Correction
The clinical supervisor and project director sat with staff and re-trained on how docuement the discharge summary and aftercare plan. The staff was also instructed on the timeline for the discharge summary completion. The clinical supervisor will perform random chart audits weekly to ensure compliance.
Clients are sent a follow up letter 30 days after discharge to document recovery maintence. The will be checked during the clinical supervisors random audits weekly. |