INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16, 2018 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 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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704.11(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 employee records conducted on January 16, 2018, the facility failed to ensure that a staff member received the required communicable disease trainings within the specified time frame.
Employee #3 was hired as counselor on 5/16/16; the HIV/Aids and TB/STD trainings were due to be completed by 5/16/17, but were not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee # 3 was scheduled for HIV training and all employees will going forward have documented training under the guidance of program director going forward. The employee files will be reviewed by director every 3 months for compliance with trainings. |
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
The project's policy and procedure manual was reviewed on January 16, 2018. The facility failed to document in the policy and procedure 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. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Seven client records were reviewed on January 16, 2018, the facility failed to update the treatment plan every 60 days in client records, #1, 2, 3, & 5.
Client #1 was admitted on 5/4/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 5/18/17; a treatment plan update was due by 7/18/17, but was not documented until 7/20/17; another update was due by 9/20/17, but was not documented until 11/4/17 and another update was due by 1/4/18, but was not documented until 1/16/18.
Client #2 was admitted on 7/21/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was documented on 8/9/17; a treatment plan update was due by 10/9/17, but was not documented until 10/11/17.
Client #3 was admitted on 6/9/17 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 10/18/17; a treatment plan update was due by 12/18/17, but was not documented until 12/22/17.
Client #5 was admitted on 4/18/17 and discharged on 9/10/17. The comprehensive treatment plan was documented on 5/2/17; a treatment plan update was due by 7/2/17, but was not documented until 7/5/17; additionally, a treatment plan update was due by 9/5/17, but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Treatment plans will be reviewed weekly by the lead counselor and monthly by the director beginning January 22, 2018 for the next 6 months to ensure compliance with updates. In addition, random chart audits will be performed to ensure compliance |