INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 21, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Spanish American Civic Association for Equality, Inc. 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
|
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on personnel records reviewed, the facility failed to provide documentation of a counselor assistant meeting the requirements of counselor within five years of employment. Also, the facility failed to provide documentation of an exception requesting additional time to meet the requirements of counselor.
Employee # 4 was hired as a counselor assistant on November 13, 2017 and was still in this position at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
the director completed an exception request for more time due to medical issues for employee 1. The facility manager will pick up the client caseload and employee number one will refrain from seeing clients until the exception letter response arrives. For future time guideline compliance the facility manager will request information 6 months before deadline date and present to director. Director will also audit employee files for compliance monthly going forward. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
|
Observations
Based on a physical plant inspection, the facility failed to keep cooking utensils in a clean and enclosed area. Cooking utensils were being stored hanging in an open area in the kitchen and stored in metal containers that were not covered.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The director purchased plastic bins to store utensils. The facility manager will be responsible to ensure that all utensils are stored in these containers. this will be accomplished by daily walk through and kitchen inspection at the start of each day going forward. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 1 was admitted on February 20, 2023 and was still active at the time of the inspection. Informed and voluntary consents from the client for the disclosure of information dated February 20, 2023 to a hospital, other medical facility, PCP, and two county offices did not include the purpose of the disclosure.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 20, 2023 to a treatment facility did not include the purpose of the disclosure.
Client # 4 was admitted on November 10, 2022 and was still active at the time of the inspection. Informed and voluntary consents from the client for the disclosure of information dated February 20, 2023 to a pharmacy and two county offices did not include the purpose of the disclosure.
Client # 6 was admitted on October 3, 2022 and was discharged on December 17, 2022. An informed and voluntary consent from the client for the disclosure of information dated October 31, 2019 to a PCP did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All consents for clients still in treatment were redone with the intake worker and resigned with client. Going forward the facility manager will review all consents within 48 hours of admission to ensure compliance with informed consent and confidentiality. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on three of four applicable client records reviewed, the facility failed to provide documentation of medication being provided as prescribed by a physician in client records # 2, 3, and 7.
Client # 2 was admitted on December 14, 2022 and was still active at the time of the inspection. The client was prescribed a medication to be taken one time daily. After a review of the facility medication administration records, there was no documentation of the medication being given on December 18, 2022.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. The client was prescribed a medication to be taken two times daily. After a review of the facility medication administration records, there was no documentation of the medication being given two times daily on February 21, 25, 27, 28, and March 1, 2023.
Client # 7 was admitted on July 13, 2022 and was discharged on October 9, 2022. The client was prescribed a medication to be taken one time daily. After a review of the facility medication administration records, there was no documentation of the medication being given on September 12, 2022 and July 16, 2022 documentation indicated the medication was given twice. Another medication was prescribed to be taken one time at bedtime. After a review of the facility medication administration records, there was no documentation of the medication being given September 21-28, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff meeting held and all staff were retrained on medication documentation. Intake staff will review medication sheets each morning and report to facility manager. Facility manager will audit all open charts weekly to ensure compliance and complete audit sheet. These sheets will be provided to director who will pull random charts to ensure compliance for the next 6 months |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in client record # 7.
Client # 7 was admitted on July 13, 2022 and discharged on October 9, 2022. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
At staff meeting director retrained all staff on documentation of clients termination to include those that leave against medical advice. The documentation must be in chart within 24 hours of client leaving treatment. Facility manager is responsible to review charts when completing discharge summary signature for all clinicians. Director will review biweekly during the chart audits for the next 6 months |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
|
Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of orienting the client to the project to include a familiarization with the fee schedule.
Client # 1 was admitted on February 20, 2023 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the fee schedule.
Client # 2 was admitted on December 14, 2022 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the fee schedule.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the fee schedule.
Client # 4 was admitted on November 10, 2022 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the fee schedule.
Client # 5 was admitted on September 1, 2022 and was discharged November 25, 2022. There was no documentation of the client being familiarized with the fee schedule.
Client # 6 was admitted on October 3, 2022 and was discharged December 17, 2022. There was no documentation of the client being familiarized with the fee schedule.
Client # 7 was admitted on July 13, 2022 and was discharged October 9, 2022. There was no documentation of the client being familiarized with the fee schedule.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Fee schedule was hung in the main lobby and added to the intake packet. Client will sign once fees are explained during the intake process. facility manager will be responsible to ensure signature page is signed and in record during weekly chart audits. Chart audit forms will be reviewed biweekly by director and random charts will be pulled to ensure compliance for the next 6 months. Facility manager will continue chart audits weekly indefinitely. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on four of seven client records reviewed, the facility failed to provide documentation of a physical examination in client records # 1, 2, 3, and 4.
Client # 1 was admitted on February 20, 2023 and was still active at the time of the inspection. There was no documentation of a physical examination.
Client # 2 was admitted on December 14, 2022 and was still active at the time of the inspection. There was no documentation of a physical examination.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. There was no documentation of a physical examination.
Client # 4 was admitted on November 10, 2022 and was still active at the time of the inspection. There was no documentation of a physical examination.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 30, 2021 and February 10, 2022 annual licensing inspections.
|
Plan of Correction
Facility manager contacted referral sources for all clients listed in observation #1757 and obtained copies of physicals, and placed them in the existing files. The facility manager will request physicals from referral sources and review before accepting the client. In the event that client or facility refuse the director has requested an exception from DDAP due to long wait times for new patients and out of county clients that are not covered in the facility county limits. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on three of seven client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in client records # 3, 5, and 6.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on January 31, 2023; however, there was no documentation of type and frequency of services.
Client # 5 was admitted on September 1, 2022 and was discharged November 25, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on September 1, 2022; however, there was no documentation of type and frequency of services.
Client # 6 was admitted on October 3, 2022 and was discharged December 17, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on October 11, 2022; however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility manager rewrote treatment plan for client still in treatment. The director retrained all staff at meeting 3/28/2023 and changed format of treatment to promote client driven goals and progress of these goals. facility manager will review treatment plan updates at case review before signing treatment plan. Director will review random charts biweekly for the next 6 months in addition to facility managers weekly audits. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
|
Observations
Based on six of seven client records reviewed, the facility failed to provide a complete client record to include a record of service that is reflective of the client's progress notes in client records # 2, 3, 4, 5, 6, and 7.
Client # 2 was admitted on December 14, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on December 15, 2022 and January 13, 2023; however, there was no documentation for those dates on the client record of service.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on January 10 and March 14, 2023; however, there was no documentation for those dates on the client record of service.
Client # 4 was admitted on November 10, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on February 28 and March 7, 2023; however, there was no documentation for those dates on the client record of service.
Client # 5 was admitted on September 1, 2022 and was discharged November 25, 2022. A review of progress notes indicates an individual session occurred on September 8 and October 27, 2022; however, there was no documentation for those dates on the client record of service.
Client # 6 was admitted on October 3, 2022 and was discharged December 17, 2022. A review of progress notes indicates an individual session occurred on October 24 and 31, 2022; however, there was no documentation for that date on the client record of service.
Client # 7 was admitted on July 13, 2022 and was discharged October 9, 2022. A review of progress notes indicates an individual session occurred on July 13 and September 25, 2022 however; there was no documentation for that date on the client record of service.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff were retrained on the regulation needs of printing, signing and filing all progress notes. Facility manager will audit weekly to ensure notes are in the file and complete and audit checklist to present to director weekly. Director will randomly audit these charts biweekly for the next 6 months |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
|
Observations
Based on seven of seven client records reviewed, the facility failed to provide a complete client record to include progress notes that are reflective of the clients record of service in client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on February 20, 2023 and was still active at the time of the inspection. A review of the record of service indicates a group session occurred on February 20, 21, 25, and March 2, 3, 4, 11, 17, 18, 20, 2023; however, there were no progress notes for those dates in the client record.
Client # 2 was admitted on December 14, 2022 and was still active at the time of the inspection. A review of the record of service indicates a group session occurred on December 14, 17, 23, 24, 25, 27, 28, 30, 31, 2022, January 1, 2, 7, 13, 14, 16, 21, 28, 29, February 3, 4, 11, 14, 15, 17, 18, 20, 21, 22, 24, 25, 28, and March 2, 3, 4, 7, 8, 10, 11, 14, 15, 17, 18, 20, 2023; however, there were no progress notes for those dates in the client record.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. A review of the record of service indicates a group session occurred on January 7, 13, 14, 16, 21, 28, 29, February 11, 1,5 17, 18, 20, 21, 22, 24, 25, 28, and March 2, 3, 4, 7, 8, 10, 11, 14, 15, 18, 17, 20, 2023; however, there were no progress notes for those dates in the client record.
Client # 4 was admitted on November 10, 2022 and was still active at the time of the inspection. A review of the record of service indicates a group session occurred on November 12, 19, 23, 24, 25, 26, December 3, 9, 10, 16, 17, 23, 24, 25, 27, 28, 30, 2022, January 1, 2, 7, 13, 14, 16, 21, 28, 29, February 3, 4, 11, 18, 20, 25, and March 2, 3, 4, 11, 18, 18, 20, 2023; however, there were no progress notes for those dates in the client record. Also, a review of the record of service indicates individual sessions occurred on November 15, 2022 and January 10, 2023; however, there were no progress notes for those dates in the client record.
Client # 5 was admitted on September 1, 2022 and was discharged November 25, 2022. A review of the record of service indicates a group session occurred on September 3, 5, 10, 17, 24, 25, October 1, 2, 8, 14, 15, 22, 29, 31, and November 12, 19, 2022 however, there were no progress notes for those dates in the client record. Also, a review of the record of service indicates individual sessions occurred on October 13, 2022; however, there were no progress notes for those dates in the client record.
Client # 6 was admitted on October 3, 2022 and was discharged December 17, 2022. A review of the record of service indicates a group session occurred on October 8, 14, 15, 22, 29, November 2, 5, 11, 12, 16, 18, 19, 23, 24, 25, 26, 30, and December 2, 3, 6, 7, 9, 10, 12, 13, 14, 2022; however, there were no progress notes for those dates in the client record.
Client # 7 was admitted on July 13, 2022 and was discharged October 9, 2022. A review of the record of service indicates a group session occurred on July 15, 16, 21, 23, 30, August 12, 13, 17, 19, 20, 24, 26, 27, September 2, 3, 5, 9, 10, 14, 16, 17, 21, 23, 24, 25, 26, 28, 29, 30, and October 1, 5, 2022; however, there were no progress notes for those dates in the client record.
These findings were viewed with facility staff during the licensing process.
|
Plan of Correction
For clients still in treatment counselors went back and updated the record of service to show dates of progress notes. Staff were retrained on the regulation of documenting the record of service page at the start of session. Facility manager will audit weekly to ensure notes are in the file and complete and audit checklist to present to director weekly. Director will randomly audit these charts biweekly for the next 6 months |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
|
Observations
Based on six of seven client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur 30, 60, and 90 days after admission.
Client # 2 was admitted on December 14, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than January 14, 2023; however, a case consultation did not occur until February 28, 2023.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. A case consultation occurred on January 28, 2023. Another case consultation was due to occur no later than March 4, 2023; however, a case consultation did not occur.
Client # 4 was admitted on November 10, 2022 and was still active at the time of the inspection. A case consultation occurred on November 15, 2022. Another case consultation was due to occur no later than January 10, 2023 and February 10, 2023; however, a case consultation did not occur.
Client # 5 was admitted on September 1, 2022 and was discharged November 25, 2022. A case consultation occurred on September 4, 2022. Another case consultation was due to occur no later than November 1, 2022; however, a case consultation did not occur.
Client # 6 was admitted on October 3, 2022 and was discharged December 17, 2022. A case consultation was due to occur no later than November 3, 2022 and December 3, 2022; however, a case consultation did not occur.
Client # 7 was admitted on July 13, 2022 and was discharged October 9, 2022. A case consultation was due to occur no later than August 13, 2022 and September 13, 2022 however, a case consultation did not occur.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility manager removed case consultation forms from separate file and placed them in the clients files. The facility manager will complete case review and ensure the form is placed in clients file after the meeting. Facility manager will audit all charts weekly to ensure compliance. Facility manger will complete audit form to present to director who will in turn complete random audits biweekly for the next 6 months. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 one of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 60 days after discharge by letter.
Client # 6 was admitted on October 3, 2022 and was discharged on December 17, 2022.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The intake worker was retrained at staff meeting. Intake worker will present copies of letters sent biweekly to facility manager. Letters sent will be marked copied and placed in file for record keeping. Facility manager will be responsible to ensure these letters are in the files by reviewing biweekly all discharge clients files for presence of letter for the next 9 months. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on three of seven client records reviewed, the facility failed to provide a complete client record to include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan in client records # 3, 5, and 6.
Client # 3 was admitted on January 4, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 31, 2023 that did not include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan.
Client # 5 was admitted on September 1, 2022 and was discharged November 25, 2022. A treatment and rehabilitation plan was developed on September 1, 2022 that did not include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan.
Client # 6 was admitted on October 3, 2022 and was discharged December 17, 2022. A treatment and rehabilitation plan was developed on October 11, 2022 that did not include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 annual licensing inspection.
|
Plan of Correction
Staff was retrained on the need to include work done in house on all treatment plans. Staff were informed that licensing would allow the word "chores" as part of the treatment plan. language changed from "life skills" and treatment plans were updated for clients still active in the program. Facility manager will audit weekly to ensure notes are in the file and complete and audit checklist to present to director weekly. Director will randomly audit these charts biweekly for the next 6 months |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for a physical examination were submitted and approved by the Department for the March 30, 2021 and February 10, 2022 annual licensing inspections. Physical examinations not documented in the client record was again found to be a deficiency in the March 21, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The director had all information updated for current clients who had negative findings. the director will meet with facility director weekly to go over chart audits and will perform additional audits for compliance going forward. Staff involved were given improvement plans and director will provide additional oversight to ensure compliance |