INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17-18, 2018 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 to be not 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of employee records conducted on January 17, 2018, the facility failed to ensure that a counselor met the educational requirements prior to being hired for the position.
Employee #5 was hired as counselor on 12/4/17, but did not possess a qualifying degree for this position. #5 has a bachelors' degree in Liberal Studies.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The staff member was demoted to counselor assistant as of 1/22/2018. The Director will now assume responsibility of verifying credentials as opposed to Human Resources or clinical supervisor going forward. |
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 11, 2017- 4pm to 7pm
November 12, 2017- 3pm to 7pm
November 18, 2017- 4pm to 7pm
November 19, 2017- 3pm to 7pm
November 25, 2017- 4pm to 11:30pm
November 26, 2017- 3pm to 7pm
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will be responsible for ensuring that at least one staff per shift are CPR certified. The director has scheduled an all staff CPR training that will be completed by March 15, 2018. To ensure compliance the current schedule has been restructured to ensure coverage for all shifts. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on January 17, 2018, the facility failed to ensure that the facility was free of hazards.
The bathroom in bedroom 3F had exposed wires protruding from the baseboard where a heater had been connected.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The building manager will be responsible for weekly walk through of the building to check for building issues. The maintenance department repaired the wires by adding a new heating box on Friday January 26,2018. |
709.28 (c) 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.
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Observations
Seven client records were reviewed on January 18, 2018, the facility failed to obtain a valid consent to release information for the client's emergency contact in client records, #1-7. Additionally a consent to release information template, for release of information to the resident's emergency contact person, stated that the consent could be revoked only by submitting a written request.
Client #1 was admitted on 11/27/17 and was an active client at the time of the licensing inspection. The consent to the emergency contact person was dated 11/28/17.
Client #2 was admitted on 11/21/17 and was an active client at the time of the licensing inspection. The consent to the emergency contact person was dated 11/21/17.
Client #3 was admitted on 11/6/17 and was an active client at the time of the licensing inspection. The consent to the emergency contact person was dated 11/6/17.
Client #4 was admitted on 7/24/17 and discharged on 8/15/17. The consent to the emergency contact person was dated 7/24/17.
Client #5 was admitted on 2/2/17 and discharged on 4/17/17. The consent to the emergency contact person was dated 2/2/17.
Client #6 was admitted on 3/30/17 and discharged on 6/4/17. The consent to the emergency contact person was dated 3/30/17.
Client #7 was admitted on 2/9/17 and discharged on 5/15/17. The consent to the emergency contact person was dated 2/9/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor has replaced erroneous template of emergency contact consent in the Master Chart. Records 1-3 were reviewed and updated emergency consents were signed by the clients and placed in the charts. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Project policy and procedure manual was reviewed on January 16, 2018. The facility policy failed to properly articulate the following elements with regard to client rights:
(5) Facility policy allows for the ' removal of ' inaccurate, irrelevant, outdated or incomplete information in their records.
This information was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy was updated by the director to reflect the current regulations. It will be submitted to the Board on January 31, 2018. Facility policy allows for the correction of inaccurate, irrelevant, outdated or incomplete information in client records by the client, but not the removal of information.
To be in compliance for the next 2 days the facility if asked to remove incorrect information will draw a line through the incorrect information and initial the change. |