INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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:
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure the clinical supervisor participate in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position.
Employee #2 was employed as a clinical supervisor on May 11, 2024 and was still in the position at the time of the inspection. Only the month of June had documented supervision.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The SUD Program Director will begin monthly supervision with the assigned clinical supervisor. Supervision will be documented on a monthly basis as it occurs and placed in staff personnel record. One week prior to the end of the month SUD Program Director will review monthly check off list to ensure all required supervisions have occurred and have been documented. Process implemented as of October 2024. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #4 was hired on October 26, 2021 and was still employed at the time of the inspection. She had no documentation of direct or close supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselor Assistant has begun direct supervision as of 10/15/24. SUD Program Director has begun direct supervision. Counselor assistant will continue direct supervision for 3 months and then switch to close supervision for 9 months. SUD program Director will be with Counselor Assistant during individual sessions and process groups. Director will document all supervisions according to licensing requirements. Effective 10/15/24. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employee #5 was hired as residential aide on June 22, 2022 and was in that position at the time of the inspection. His training was due no later than June 22, 2024; however, none was completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #5 will complete HIV/AIDS and TB/STD/and other health related topics trainings by 10/31/24. SUD Program Director and Quality Assurance will continue monitoring personnel chart for completion and or pending trainings. Personnel chart audits will be completed monthly by SUD program Director. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from December 2023 through September 2024, the facility failed to conduct an unannounced fire drill at least once a month. There were no drills documented during the months of December, 2023; January, March and April, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills will be completed once a month unannounced. The staff to conduct the fire drills have been trained on the procedure for conducting the drills and the importance of remaining in compliances with the policy to conduct these. SUD Program director will monitor these drills and ensure that drills are completed monthly via end of month check off list. Implementation effective 10/2024. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from December 2023 through September 2024, the facility failed to maintain a written fire drill record including whether the fire alarm or smoke detector was operative in May and August, 2024. Additionally, the fire drill record did not indicated the time of the drill in February, June, July and September, 2024; and problems encountered missing in May, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The fire drill forms have been updated to include: the time of the drill, as well as if the fire alarm or smoke detector were working, and any problems encountered. There has also been a bold statement added to the form stating all areas of the form must be completed. The SUD Director will review the form immediately after the drill for inspection of completion in its entirety. Effective October 2024. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from December, 2023 through September, 2024 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was only completed on August 22, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills will be completed once a month unannounced. Every 6 months these fire drills will be conducted during sleeping hours. The staff to conduct the fire drills have been trained on the procedure for conducting the drills and the importance of remaining in compliances with the policy to conduct these. SUD Program director will monitor these drills and ensure that drills are completed monthly via end of month check off list. Implementation effective 10/2024. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies within seven days of hire.
Employee #1 was hired on September 3, 2024 as the Project Director/Facility Director and was still in the position as of the date of the inspection. The training was completed on September 16, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The SUD Program Director will ensure all new hires complete on day 2 of employment the individual training plan, which includes the Emergency/Safety plan. The SUD Program Director, will ensure the required training is completed within the first 7 days of employment. Monthly personnel chart checks will then be completed for any pending trainings that need completed. In the instance that the new hire is the Program Director, the Quality Assurance Director will ensure that all required trainings are completed with in the mandated time frames. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed at seven and fifteen days following discharge. No follow up was documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When a client is discharged the counselor will prepare the seven and fifteen day follow up letters. The front office staff will then send out these letter in the designated time frame (7 and 15 days). The front office will also make a phone call to attempt contact via phone as well. The front office will then document the phone call and phone call results in the clients chart. SUD Director will audit all discharge charts to confirm this process and documentation have been completed. Effective October 2024. |