INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2008 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 29, 2008.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a February 6, 2008 review of training records, the facility failed to document HIV/AIDS and TB/STD in one of one record reviewed, #1.
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Plan of Correction
HIV/Aids and TB/STD training will be held for the staff on March 6, 2008. The training will be repeated in May, 2008. All new staff and current staff will have recieved the training by May. The Project Director and Clinical Supervisor will document and ensure that all staff are trained. |
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 February 6, 2006 review of training records, the facility failed to document a sufficient number of staff persons trained in CPR and first aid during the project's hours of operation. No employees in the drug and alcohol facility were certified in CPR or trained in first aid.
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Plan of Correction
Staff will receive CPR and First Aid training by April 1, 2008. The Project Director and Clinical Supervisor will document and ensure that the staff are trained. |
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 February 6, 2008 review of personnel records, the facility failed to document fire extinguisher training within the required time frame in one of two records reviewed, #2.
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Plan of Correction
The staff will receive Fire extinguisher training by the 7th day of hire. The Project Director and Clinical Supervisor will ensure and record the training. |
709.28(c)(2) 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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a February 6, 2008 review of client records, the facility failed to obtain an informed and voluntary consent to release information in two of three records reviewed, #2 and 4. The specific information to be disclosed was not documented.
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Plan of Correction
The Clinical Supervisor will review the client charts to ensure that all consent forms are properly completed and signed. This will be done at the weekly case eviews. |
709.28(c)(6) 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 shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Based on a February 6, 2008 review of client records, the facility failed to document the expiration date of the consent in two of three records reviewed, #2 and 4.
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Plan of Correction
The Clinical Supervisor will ensure that all consent forms are properly dated, including the expiration date. This will be done at the weekly case review. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a February 6, 2008 review of client records, the facility failed to document whether or not a copy of the client consent was offered to the client in two of three records reviewed, #2 and 4.
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Plan of Correction
The Clinical Supervisor will ensure that client consent forms are properly completed and that the client is offered a copy of the consent form. This will be documented in the client's file and will be examined at the weekly case review. |
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 February 6, 2008 review of client records, the facility failed to document psychosocial evaluations in three of four client records reviewed, # 2, 3 and 4.
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Plan of Correction
The Clinical Supervisor will work with the new Outpatient Drug & Alcohol Counselor to ensure that the psychosocial evaluations are correctly completed and fully documented. This will be routinely monitired during the weekly case reviews. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a February 6, 2008 review of client records, the facility failed to document a comprehensive treatment plan in one of four client records reviewed, #4.
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Plan of Correction
The Clinical Supervisor will review the client records at the weekly case review to ensure that the treatment plans are complete and comprehensive |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a February 6, 2008 review of client records, the facility failed to document the duration of treatment on the record of service in four of four client records reviewed, # 1, 2, 3 and 4.
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Plan of Correction
The Clinical Supervisor will ensure that all session notes are fully and properly documented in the record of service. The record of service will be examined during the weekly case reviews. |