INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion was found to not 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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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 CPR cards and review of the facility's schedule, the facility failed to provide CPR coverage for the following shifts:
November 17, 2018- 5 pm to 12 midnight
November 18, 2018-12 pm to 8 am
November 18, 2018-5 pm to 12 midnight
November 19, 2018-12 midnight to 8 am
November 24, 2018-5 pm to 12 midnight
November 25, 2018- 12 midnight to 8 am
November 25, 2018-5 pm to 12 midnight
November 26, 2018-12 midnight to 8 am
December 1, 2018-7 pm to 12 midnight
December 2, 2018- 12 midnight to 7 am
December 2, 2018-7 pm to 12 midnight
December 3, 2018 12 midnight to 8 am
December 8, 2018- 5 pm to 12 midnight
December 9, 2018- 12 midnight to 8 am
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the annual inspection held on January 18, 2018.
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Plan of Correction
The 2 staff that were not trained took CPR and passed 2/22/19.
They will be added to the agency list for recertification in 2020, so everyone will then again be certified.
The house manager supervisor will be responsible to ensure that the support staff is trained upon hire or within the first 30 days.
The House Manager Supervisor will ensure the Director is made aware if new hires do not have CPR when they start work. House Manager Supervisor will cover shift until new hires are trained if needed. Clinical Supervisor will schedule trainings in between company wide CPR trainings going forward. The two staff have full time jobs in addition to employment at NCR which caused the delay in training/ |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
During a physical site inspection conducted on February 8, 2019, the facility failed to have slip-resistant surfaces in all bathtubs and showers.
Three out of six bathrooms were missing slip-resistant surfaces in the showers.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clients had removed the non stick surface mats mats. House Manager Supervisor replaced mats on 2/20/19 and will do a walkthrough each morning and evening to ensure they are not taken out of the tubs. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
During an onsite inspection on February 8, 2019, the facility failed to secure the client's records within a locked storage container.
The client records which were kept in a cabinet in the foyer of the building were left unattended and unlocked.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The office manager and all counselors were retrained the cabinet must be locked at all times when not taking out or putting a record in, by Clinical Supervisor. Additionally, support staff were retrained on 2/22/19. Random daily checks by director and supervisor will be completed to ensue compliance with keeping the cabinet locked at all times going forward with no end date. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
During a review of seven client records on February 8, 2019, the facility failed to obtain an informed and voluntary consent from the client for disclosure of information contained in the client's record.
Client #1 was admitted on December 10, 2018 and was discharged on February 8, 2019. Client #1 had a signed and dated release of information for Matt the Social Worker that did not contain what specific information was to be disclosed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselors and Office Manager were retrained on the process of completing consents and obtaining an informed and voluntary consent from the client for disclosure with 100% compliance. Clinical supervisor will be responsible for checking the 5 points of specific information that can be disclosed randomly each week for 6 months then randomly going forward.. The clinical supervisor also pulled all general consents, and staff will use the formatted consents choosing which if any of the points the client wants to release. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During an inspection of seven client records on February 9, 2019, the facility failed to ensure that they had written policies and procedures to address all client rights.
Client #1 was admitted on December 10, 2018 and was discharged on February 8, 2019. Client #1 had not been informed that the project does not discriminate on the basis of marital status.
Client #2 was admitted on December 2, 2018 and was active at the time of the inspection. Client #2 had not been informed that the project does not discriminate on the basis of marital status.
Client #3 was admitted on December 9, 2018 and was active at the time of the inspection. Client #3 had not been informed that the project does not discriminate on the basis of marital status.
Client #4 was admitted on December 19, 2019 and was active at the time of the inspection. Client #4 had not been informed that the project does not discriminate on the basis of marital status.
Client #5 was admitted on November 5, 2018 and was discharged on December 10, 2018. Client #5 had not been informed that the project does not discriminate on the basis of marital status.
Client #6 was admitted on November 16, 2018 and was discharged on January 9, 2019. Client #6 had not been informed that the project does not discriminate on the basis of marital status.
Client #7 was admitted on November 12, 2018 and was discharged on January 15, 2019. Client #7 had not been informed that the project does not discriminate on the basis of marital status.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Missing language "marital status" was added to the client rights policy and all clients in facility were updated and signed the new form. Clinical Supervisor will audit biweekly for 6 months then monthly to ensure compliance with use of new forms. New formatted form will be used for all new clients. |