INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18 through 19, 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 January 13, 2009.
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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 the review of administrative documentation, the facility failed to ensure that one of one employees FTE caseload did not exceed 35 active clients.
The findings include:
Administrative records regarding caseloads were reviewed on December 19, 2008. Employee # 2 has a client to counselor caseload ratio of 45 to 1.
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Plan of Correction
Inactive cases closed appropriately by Employee #2. FTE Employee #2 in the process of being transferred to strictly addiction treatment by February 1, 2009 with caseload not to exceed 35 to 1.
Project director is in charge of transition and will monitor caseloads at weekly case review. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant walk through inspection, the facility failed to ensure the trash container was covered.
The findings include:
The physical plant was inspected on December 18, 2008. The facility had one dumpster at the back of the parking lot and it was not covered as required. The facility did not ensure that the dumpster had lids to make it a covered trash container.
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Plan of Correction
Facility director submitted requisition on January 21, 2009 to property owner to replace defective trash container.
Facility director to monitor situation daily to ensure dumpster is replaced with one with lids. |
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 facility records, the facility failed to document that the governing body was presented the policy and procedures manual on an annual basis.
The findings include:
Facility administrative records were reviewed on December 18, 2008. The facility had no documentation that the policy and procedures manual was presented to the governing body for the 08-09 fiscal year.
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Plan of Correction
Facility director to present governing body with policy and procedures manual on January 28, 2009. Board chair to sign documentation of presentation. |
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 facility records, the facility failed to present goals and objectives to the governing body on an annual basis.
The Findings include:
Facility administrative records were reviewed on December 18, 2008. The facility had no documentation that goals and objectives for the 08-09 fiscal year were presented to the governing body.
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Plan of Correction
Facility director to present FY 08-09 goals and objectives to governing body on January 28, 2009. Board chair will sign documentation of presentation. |
709.23(b)(3) 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:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of facility records, the facility failed to document a performance report that summarized progress towards meeting facility goals and objectives.
The findings include:
Facility administrative records were reviewed on December 18, 2008. The facility had no documentation of a report summarizing the progress towards meeting goals and objectives for the 07-08 fiscal year.
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Plan of Correction
Facility director will present performance report that will summarize progress towards goal and objectives for the 07-08 fiscal year to the governing body on January 28, 2009. Chair board will sign documentation of presentation. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document personal histories in two of two client records.
The findings include:
Four client records were reviewed on December 19, 2008. Personal histories were required in two client records. The facility failed to include family histories, employment/vocation histories, education histories and recreational histories as well as identify the effects of client drug and alcohol use/abuse on leisure time activities in client records # 1 and 2.
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Plan of Correction
FTE counselor responsible for inadequate documentation notified on
December 19,2008.
Facility director to hold on-site training on Proper Record Documentation for clinical staff on January 29, 2009. |
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 review of client records, the facility failed to document complete psychosocial evaluations in two of two client records.
The findings include:
Four client records were reviewed on December 19, 2008. Psychosocial evaluations were required in two client records. The facility failed to include a composite picture and client strengths in client records # 1 and 2. The facility did not document support systems or coping mechanisms in client record # 2.
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Plan of Correction
FTE counselor notified of inadequate documentation on December 19, 2008.
Facility director to hold on-site training in Proper Record Documentation for clinical staff on January 29, 2009.
Facility director to monitor charts at weekly case reviews and periodic random checks.
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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 the review of client records, the facility failed to document medication records in one of one client records.
The findings include:
Four client records were reviewed on December 19, 2008. Medication records were required in one client record. The facility did not document dose or frequency of medication in client record # 2.
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Plan of Correction
Facility director to hold on-site training in Proper Record Documentation for clinical staff on January 29, 2009.
Facility director to monitor charts at weekly case reviews and periodic random checks
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