INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 2025 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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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.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of two applicable records reviewed.
Client #4 was admitted on February 10, 2025 and was discharged on April 23, 2025. A comprehensive treatment plan was completed on February 19, 2025 and an update was due no later than April 21; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Weekly random audits of client records will be conducted by the Director of Quality Control to ensure all Treatment Plans are completed in a timely manner once the facility reopens. Standardized auditing tools have been developed and will be shared with the SUD Director to support staff accountability and monitor compliance. Continued noncompliance may result in progressive disciplinary action, up to and including termination. |
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 document follow up information within guidelines established by the facility's policy and procedures manual in five out of five applicable records reviewed. The facility's policy and procedures manual states that follow-up must be completed at seven and 15 days following discharge.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the October 8, 2024 licensing inspection.
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Plan of Correction
When the facility reopens, The appointed SUD Director will review all policies and procedures with new staff. Flags will be placed in the client's EMR upon discharge by the Counselors and may only be marked as resolved by the SUD Director after the Counselor or Case Manager provide documented evidence that follow-up has occurred after discharge. These flags will include due dates and serve as alerts to ensure staff complete required follow-up actions accurately and on time. |