INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4 through 5, 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 September 5, 2008.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a August 4 through 5, 2008 review of facility records, the facility failed to ensure that one out of one counselors had a client to counselor caseload at or under 35 to 1.
Finding:
Employee # 2 had a client to counselor caseload of 68 to 1.
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Plan of Correction
Project Director is currently interviewing for an additional counselor to bring caseloads into ratio compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on an August 4 through 5, 2008 review of facility documentation, the facility failed to document whether or not a fire alarm or smoke detector was set off during each fire drill.
Finding:
The facility did not include documentation in the fire drill logs of the use of fire alarms or smoke detectors to initiate the fire drills.
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Plan of Correction
Fire drill log documentation changed to include use of fire alarms or smoke detectors.
Facility director will monitor documentation after each fire drill and sign off on correctly completed documents. |
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 an August 4 through 5, 2008 review of five client records, the facility failed to properly document specific information to be disclosed in one of five client records and exceeded the limits imposed at 4 Pa. Code Subsection 255.5(b) for information released to probation officers.
Finding.
A consent to release form documented that drug screen results would be released to the client's probation officer in client record # 2.
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Plan of Correction
Clinical staff training held in which project director instructed clinical staff in proper usage of terminology for consent forms.
All facility consent forms reviewed and changed to ensure client confidentiality.
Project director will monitor for proper terminology on consent forms at weekly case reviews and monthly quality control checks. Administrative supervisor will review consent forms as completed. |
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 an August 4 through 5, 2008 review of five client records, the facility failed to indicate whether or not the client was offered a copy of the consent to release information form in three of five client records.
Finding:
Documentation demonstrating that the client was offered a copy of the consent to release information form was missing from client records # 1, 2 and 3.
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Plan of Correction
Quality control training held to reiterate importance of completion of all elements in release information form.
Basic information release form changed to include check boxes for client acceptance or refusal of copy of release form.
Project director will monitor for properly completed consent forms at weekly case reviews and monthly quality control checks. Administrative supervisor will review consent forms as completed. |
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 an August 4 through 5, 2008 review of five client records, one client record was required to have a treatment plan update. The facility failed to document a treatment plan update in one of one client records.
Finding:
Documentation in one of one client records was missing a treatment plan update, specifically client record # 3.
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Plan of Correction
Quality Control held training stressing importance of currency of treatment planning. Clinicians and quality control to thoroughly inspect required documentation at weekly case review and monthly quality control checks. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on an August 4 through 5, 2008 review of five client records, the facility failed to document dosage and frequency of use of medication in one of one client records where required.
Finding:
Documentation regarding the dosage and frequency of use of medication was missing from client record # 3.
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Plan of Correction
Clinic psychiatrist in attendance at quality control training held on proper documentation. Quality control team instructed by facility director to review medication records. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on an August 4 through 5, 2008 review of five client records, one client record required an aftercare plan but the facility failed to complete an aftercare plan in one of one record where aftercare plans were required.
Finding:
The aftercare plan was missing from client record # 4.
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Plan of Correction
Quality control training on proper documentation held by facility director.
Clinicians and quality control instructed to be aware of need for aftercare planning. Quality control and clinicians review documentation at weekly case review and monthly chart reviews. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on an August 4 through 5, 2008 review of five client records, two client records reviewed required discharge summaries, but the facility failed to document a discharge summary in one of two records where required.
Finding:
Documentation of a discharge summary was missing from client record # 5.
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Plan of Correction
Quality contol training on proper documentation held by facility director.
Documents checked by clinicians, facility director at weekly case review and by clinicians and quality control team at monthly chart review. |
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 an August 4 through 5, 2008 review of five client records, the facility failed to document follow-up information in two of two client records where the documentation was required.
Finding:
The facility did not document follow-up information in client records # 4 and 5.
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Plan of Correction
Quality control training on documentation held by facility director.
Clinicians and quality control review charts and documentation at weekly case review and monthly chart review. Administrative assistant assigned to provide additional review of aftercare and follow-up at time of client discharge. |