INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 15, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Nuestra Clinica Rehabilitacion was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 April 15, 2025, it was observed that the facility failed to ensure the grounds were safe and in good repair at all times.
Bedroom D, on the third floor, was observed to have a bank of windows with a cracked glass panel.
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Plan of Correction
On 4/29/2025, Nuestra Clinica Residential maintenance , removed the cracked glass from the bank of windows on bedroom D, 3rd floor. The tempered window glass was then protected with plexiglass. A photo of the repair has been sent to the DDAP auditor via email. SUD Program Director will ensure routine facility checks are completed by second shift residential aide. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on April 15, 2025, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
During a physical plant inspection, DDAP staff observed the facility's bank of video camera images and saw live video of the group that was in session at that time.
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Plan of Correction
Nuestra Clinica Residential Maintenance supervisor was able to identify the camera cable for the group room and has tagged these. Camera cables will be disconnected by NCR Front Office staff every morning before 8am and will reconnect the cable at 3pm when no other groups will be provided by the counselor on duty. This process began on 4/17/25 and will continue daily moving forward. SUD Program Director will ensure this is completed daily as evidenced by sign off sheet. |