INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4 & 5 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on review of the Staffing Requirements Facility Summary Report the facility failed to ensure that they had a clinical supervisor or counselor to provide supervision for each counselor assistant employed.
The findings include:
Based on the review of the Staffing Requirements Facility Summary Report on January 4, 2010 and an interview with the project director on January 5, 2010, the facility failed to employ a counselor or clinical supervisor for every counselor assistant.
Employee #2 meets the qualification for clinical supervisor, however the facility employed three counselor assistants, specifically employee numbers 3, 4, and 5. There are no additional counselors.
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Plan of Correction
Employees #s 4 + 5 are no longer seeing clients.Census has been limited to 16 clients. Facility is actively seeking to employ a FT Certified Addictions Counselor so that we can resume admission of clients at full capacity by March 1, 2010.
Project Director will monitor caseloads at weekly case review.
Agency has hired a FT Certified Addictions Counselor scheduled to start February 22, 2010. New clinician will provide supervision to Employee #4 who is not not acting as an assistant counselor nor seeing clients at this time.
Employee #5 will be leaving the agency on February 19, 2010.
In the future Project director will ensure that clinical supervision will be provided to each counselor assistant by a single qualified counselor. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff training records, CPR/first aid certification cards and an interview with the Operations Manager/Counselor Assistant, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and first aid to allow 24 hour coverage.
The findings include:
Seven personnel records and ten employee CPR/first aid certification cards were reviewed on January 5, 2010. In a review of the schedule for the past four weeks the facility failed to ensure 24 hour first aid/CPR coverage was provided on a daily basis. An interview with the Operations Manager/Counselor Assistant on January 5, 2009 confirmed the facility's failure to provide 24 hour first aid/CPR coverage. The interview revealed that new staff members had not yet had first aid/CPR training.
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Plan of Correction
All employees shall obtain CPR certification within the first 30 days of hire.The next available training will be January 30, 2010. The new staff will attend.The schedule will be rotated to ensure that at least one person trained in these skills is onsite during the project's hours of operation.
Operation Manager will present each week's schedule to the Project Director
who will verify the above. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to provide documentation of cold food being stored at or below 40F and frozen food being stored at or below 0F.
The findings include:
The physical plant was inspected on January 4, 2010 between 1:00 pm to 2:00 pm. Four refrigerators/freezers are provided for client food storage . There were no thermometers for three freezers and two refrigerators, making it impossible to determine the cold storage temperatures in each of these units. Additionally, one freezer had a thermometer, however the facility failed to provide documentation on the temperature log that specified the temperature of this frozen food storage unit.
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Plan of Correction
Thermometers were purchased on the first day of the inspection,and placed in all refrigerators and freezers. The appliances have been numbered and labeled for identification purposes.
Temperature checks take place once a shift by the House Manager and documented on newly updated forms that include: location of refrigerator/freezer, time and date of check, temperature and House Managers' initials verify the readings. Any irregularities in temperature will be reported to the Operations Manager who will also check the documentation daily. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records it was determined that the facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment.
The findings were:
A review of seven personnel records revealed that seven employees were not instructed in the use of a fire extinguisher upon their employment, specifically employees #1, 2, 3, 4, 5, 6 and 7.
A discussion with the facility director and operations manager on January 5, 2010 confirmed there was no documentation that the identified employees received instruction in the use of a fire extinguisher.
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Plan of Correction
All staff training was given in fire extinguisher use was given on January 19, 2010 by Operation Manager, documented and placed in employee files.
In the future all new employees will be given fire extinguisher instruction as part of orientation and documented and verification placed in personnel files.
Project Director will review complete orientation within first 7 days and initial. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of administrative fire drill log the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
Based on a review of the administrative fire drill log on January 4, 2010, the facility's documentation of fire drills failed to include the time it took for the evacuation, the exit route used, and whether or not the alarm was operative. This information was missing on all fire drill records reviewed.
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Plan of Correction
A newly designed form was shown to the Inspector at the time of the visit and is now being utilized. The form documents the date,time, the exit route used, the number of persons in the facility at the time of the drill, any problems encountered and whether the the fire alarm or smoke detector was operative.
The Operations Manager will review the completed form in the log after each drill and report any discrepancies to the Project Director. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) 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 administrative fire drill logs on January 4, 2010 the facility failed to document exit routes utilized for evacuation for the last twelve months.
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Plan of Correction
New document now in use includes use of alternating exits to ensure knowledge of all exit routes available to styaff and clients. Operations Manager will verify in fire log and report to Project Director. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of administrative fire drill logs, the facility failed to document that a fire alarm was activated during each fire drill.
The findings include:
Based on a review of administrative fire drill logs on January 4, 2010, the facility failed to document that the fire alarm was activated in ten out of twelve months, specifically January 09, February 09, March 09, June 09, July 09, August 09, September 09, October 09, November 09, and December 09.
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Plan of Correction
The new fire alarm form,implemented the day of the inspection,documents the activation of the fire alarm during fire drill. The fire department will be notified prior to the drill that the alarm will be sounded.
Operations Manager will provide the documentation and Project Director will review and initial. |
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 the public the 2008 annual report available to the public.
The findings include:
The 2008 annual report was reviewed on January 4, 2010. The facility is publicly funded and required to make available an annual report available to the public. The 2008 fiscal year ended on June 30, 2009. The project director stated on January 5, 2010 that the 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. The project director will remind the corporate office to make this information in a timely fashion on a yearly basis |
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 4 and 5, 2010. The facility failed to provide 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 drug and alcohol licensing inspection.
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Plan of Correction
Project director presented the Board of Directors with the Policies and Procedures on January 27, 2010 and the Chairman signed off.
In the future the Project Director will present them to the Board at the first meeting of the new fiscal year for review and verification. |
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 it was determined that the goals and objectives for the fiscal year of July 1, 2008 to June 30, 2009 were not presented to the governing body. Additionally, a review of administrative documentation and an interview with the project/facility director confirmed that the project had developed goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010, however they failed to include time frames, available resources and present them to the governing body for review.
The findings were:
A review of administrative documents on January 4 and 5, 2010 indicated that the annual goals and objectives for the fiscal year of July 1, 2008 to June 30, 2009 were not presented to the governing body.
Based on a review of administrative documents on January 4 and 5, 2010, there was no documentation that indicated that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 were presented to the governing body. Additionally the goals and objectives that were in place, failed to indicate time frames and available resources.
An interview with the project/facility director on January 5, 2010, confirmed that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 had not been presented to the governing body.
This is a repeat deficiency. The facility was previously cited at the conclusion of the December 16-17, 2008 drug and alcohol licensing inspection.
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Plan of Correction
Project director presented the governing board with the Goals and Objectives on January 27, 2010 for the fiscal year 2009-2010 along with a mid-year evaluation/review and the Chairman signed off.
In the future the Project Director will develop Goals and Objectives with the agency CEO and present them in a format that includes specific time frames and available resources to the governing board for review and verification at the first board meeting of the fiscal year. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to document the results of a reference investigation in four of seven personnel records.
The findings include:
Seven personnel records were reviewed on January 4 and 5, 2010. Seven personnel records required reference investigations. Personnel record # 1, 2, 6, and 7 did not include the results of a reference investigation.
Employee # 1 was hired for his current position on July 23, 2008. There was no documentation of a reference investigation.
Employee #2 was hired for his current position on August 1, 2008. There was no documentation of a reference investigation.
Employee # 6 was hired for his current position on July 21, 2009. There was no documentation of a reference investigation.
Employee # 7 was hired for his current position on October 19, 2009. There was no documentation of a reference investigation.
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Plan of Correction
A new agency-wide policy was implemented at the end of calendar year 2009 whereby initial refence checks must be completed and documented.Once this is complete the reference checks will be submitted to the corporate office and then the CFO and CEO will review the references and either supply written approval or denial as to whether
or not the organization will pursue the prospective employee.
The Operations Manager will be responsible for the initial reference checks and will report to the Project Director the results. We will then submit to the corporate office. |
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.
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Observations
Based on client record review and a conversation with the staff, the facility failed to document a follow up attempt in two of three client records.
The findings include:
Six client records were reviewed on January 4 and 5, 2009. Three of the client records reviewed were discharged records and required follow up information. The facility failed to document a follow up contact in client records # 5 and 6. The facility policy stated that follow up letters will be sent to all clients who are discharged within thirty days and seven days of discharge if a client is referred to an outside agency.
Client #5 was admitted on 8-06-09 and discharged on 8-31-09. A follow up attempt was due on 9-30-09. The facility failed to document a follow-up attempt as of the date of inspection.
Client #6 was admitted on 7-09-09 and discharged on 8-20-09. A follow up attempt was due on 9-20-09. The facility failed to document a follow-up attempt as of the date of inspection.
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Plan of Correction
The Operations Manager will be responsible for follow up information. The Operations Manager will contact the outside agency if a client is referred to verify continued involvement in treatment. The results of this contact will be documented in a newly designed form now in effect.
The Operations Manager will also be responsible for follow up letters to clients within thirty days of discharge and document these contacts and the results of such contacts.
The Project Director will review discharged records on a monthly basis to ensure these follow up contacts have been made and documented. |