INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2022 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 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:
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Plan of Correction
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705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on the facility physical plant inspection, the facility failed to maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
An exit to the back of the building has a chain link fence with locks and vines that prevent the fence from being opened which creates a danger to health and safety.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director labeled the door to indicate it was not an emergency exit, and clinical supervisor will check weekly to ensure the sign remains in tact. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.17(a)(3) Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for an informed and voluntary consent form from the client for the disclosure of information to include the purpose of the disclosure were submitted and approved by the Department for the December 21, 2020, January 14, 2022, and July 19, 2022 annual licensing inspections. Obtaining an informed and voluntary consent form from the client for the disclosure of information to include the purpose of the disclosure were again found to be a deficiency in the December 7, 2022 licensing inspection.
Plans of corrections for assuring that counseling services are provided according to the individual treatment and rehabilitation plan were submitted and approved by the Department for the July 19, 2022 and January 14, 2022 annual licensing inspections. Assuring that counseling services are provided according to the individual treatment and rehabilitation plan were again found to be a deficiency in the December 7, 2022 licensing inspection.
Plans of corrections for a complete client record on an individual which includes information relative to the client's involvement with the project to include progress notes were submitted and approved by the Department for the July 19, 2022 and January 14, 2022 annual licensing inspections. A complete client record on an individual which includes information relative to the client's involvement with the project to include progress notes were again found to be a deficiency in the December 7, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical supervisor has been placed in leadership role to ensure compliance with POC. The executive director will meet weekly with clinical supervisor for the next 6 months and document compliance with the correction plan after viewing documents that support the plan. After 6 months meeting will occur monthly with compliance at 90% or higher. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 2 was admitted on October 3, 2022 and was discharged on November 14, 2022. An informed and voluntary consent from the client for the disclosure of information dated October 3, 2022 to a "friend" did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 21, 2020, January 14, 2022, and July 19, 2022 annual licensing inspections.
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Plan of Correction
Clinician responsible for the notes was given supervision, retraining and a PIP. The director will provide clinician weekly supervision and case review. The clinical supervisor will audit all charts from each day the next morning and provide update to director at weekly supervision for the next 9 months then weekly random audits will take place |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.
Client # 8 was admitted on September 23, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated September 23, 2022 to a probation officer and court did not have a valid signature by the client but did provide the dated signature of the witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client was contacted by clinician and ask to resign, date and complete a new consent. Clinician responsible for the notes was given supervision, retraining and a PIP. The director will provide clinician weekly supervision and case review. The clinical supervisor will audit all charts from each day the next morning and provide update to director at weekly supervision for the next 9 months then weekly random audits will take place |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based off a request for a current client census, the facility failed to provide recordkeeping system that allowed for the identification of clients ' admissions and discharges within a specific time period. Client # 8 is an active client and was not listed on the current client list provided by the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director retrained clinician on the need to discharge charts completely to ensure accurate record keeping. In addition census was updated in the Electronic Health Record(EHR) system. Clinical supervisor will monitor the active records weekly for compliance through the EHR system for the next 6 months. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on five of eight client records reviewed, the facility failed to shall assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 3, 5,6, and 7.
Client # 1 was admitted on September 21, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 5, 2022 indicating individual and group sessions to occur weekly. There is no documentation of group notes occurring weekly in the client record.
Client # 3 was admitted on May 17, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 13, 2022 and updated August 12 and October 13, 2022 indicating individual sessions to occur weekly. There is no documentation of group notes occurring weekly in the client record. A review of the client record of service and progress notes indicate the last counseling session occurred on November 3, 2022
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Client # 5 was admitted on June 23, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on July 7, 2022 and updated September 7, 2022 indicating individual and group sessions to occur weekly. There is no documentation of group notes occurring weekly in the client record. A review of the client record of service and progress notes indicate the last counseling session occurred on November 14, 2022
Client # 6 was admitted on February 17, 2022 and was discharged August 29, 2022. A comprehensive treatment plan was developed on March 14, 2022 indicating individual and group sessions to occur weekly. Updates occurred May 14 and July 14, 2022 indicating individual sessions occur weekly. There is no documentation of group notes occurring weekly in the client record for the months of March 14-May 14, 2022.
Client # 7 was admitted on February 2, 2022 and was discharged July 26, 2022. A comprehensive treatment plan was developed on March 15, 2022 indicating individual and group sessions to occur weekly. There is no documentation of group notes occurring weekly in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 14, 2022, and July 19, 2022 annual licensing inspections.
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Plan of Correction
The director retrained clinician on client centered treatment plans. The removal of group therapy from the plans until or unless a patient attend that therapy. Direct supervision of groups was reinstated and charts will be reviewed daily for the next 6 months and if at 90% or higher compliance random audits will occur weekly. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on four of eight client records reviewed, the facility failed to provide a complete client record to include progress notes that are reflective of the clients record of service in client records # 3, 5, 6, and 7.
Client # 3 was admitted on May 17, 2022 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on July 8, 11, August 8, 22, 30, September 7, 15, 29, and October 20, 2022 however, there were no progress notes for those dates in the client record.
Client # 5 was admitted on June 23, 2022 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on July 14, 27, August 8, 22, September 12, and November 14, 2022 and group sessions occurred on July 5, 12, 19, 26, September 27, October 17, 19, 26, and November 19, 2022 however, there were no progress notes for those dates in the client record.
Client # 6 was admitted on February 17, 2022 and was discharged on August 29, 2022. A review of the record of service indicates an individual session occurred on February 25, March 22, 29, April 4, 11, 18, and June 14, 2022 however, there were no progress notes for those dates in the client record.
Client # 7 was admitted on February 2, 2022 and was discharged on July 26, 2022. A review of the record of service indicates an individual session occurred on March 29, April 5, 2022 however, there were no progress notes for those dates in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 14, 2022, and July 19, 2022 annual licensing inspections.
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Plan of Correction
Clinician responsible for the notes was given supervision, retraining and a PIP. The director will provide clinician weekly supervision and case review. The clinical supervisor will audit all charts from each day the next morning and provide update to director at weekly supervision for the next 9 months then weekly random audits will take place |
709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on four of six applicable client records reviewed, the facility failed to provide a complete client record to include client-related correspondence for authorizations for funding. A review of client records and discussion with facility indicated authorizations were completed for funding however, was not documented in the client record in records # 1, 3,4,5.
Client # 1 was admitted on September 21, 2022. There were no authorizations documented in the client record.
Client # 3 was admitted on May 17, 2022. There were no authorizations documented in the client record.
Client # 4 was admitted on October 20, 2022. There were no authorizations documented in the client record.
Client # 5 was admitted on June 23, 2022. There were no authorizations documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director went over and retrained clinician in the process of authorizations, service coordination and correspondence documentation and consent to discuss these processes with funding stream. Director responsible for direct supervision of clinician, The clinical supervisor will audit charts daily for the next 6 months then random weekly audits will occur on an ongoing basis. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on four of four applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur with treatment plan updates.
Client # 3 was admitted on May 17, 2022 and was still active at the time of the inspection. A treatment plan update occurred on July 7, 2022 and October 13, 2022. There was not a case consultation that occurred with the treatment plan updates.
Client # 5 was admitted on June 23, 2022 and was still active at the time of the inspection. A treatment plan update occurred on August 12, 2022 and September 7, 2022. There was not a case consultation that occurred with the treatment plan updates.
Client # 6 was admitted on February 17, 2022 and was discharged on August 29, 2022. A treatment plan update occurred on March 14, 2022 and July 14, 2022, and May 14, 2022. There was not a case consultation that occurred with the treatment plan updates.
Client # 7 was admitted on February 2, 2022 and was discharged on July 26, 2022. A treatment plan update occurred on March 15, 2022 and May 31, 2022. There was not a case consultation that occurred with the treatment plan updates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinician was given supervision, retraining and a PIP. The director will provide and attend weekly case review and therapist will file the form in clients chart. The supervisor will audit all charts from each day the next morning and discuss at weekly supervision for the next 9 months then weekly random audits will take place |