INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 21, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Spanish American Civic Association for Equality 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on staff interviews and a review of the Confidentiality and Consents policy, the facility failed to follow their written procedures for the security of client records.
The Confidentiality and Consents policy indicates that individual files will be kept locked in filing or storage cabinets.
Per staff interviews, it was learned that client records are taken out of the facility for a contracted consultant to perform audits on the client records.
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Plan of Correction
Client records will remain at facility a all times in locked file cabinet. On Fridays the contracted consultant will present to the facility for any scheduled chart audits, therefore allowing for client charts to remain at respective facility. SUD Program Director will ensure this processed is followed at all times, effective 12/02/24. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three of six client records reviewed.
Client # 1 was admitted on 9/18/24 and was still active at the time of the investigation. A treatment plan was completed on 9/25/24. The next update was due no later than 10/25/24; however, there was no update documented in the record.
Client # 3 was admitted 9/11/24 and was still active at the time of the investigation. A treatment plan was completed on 10/14/24. The next update was due no later than 11/14/24; however, there was no update documented in the record.
Client # 4 was admitted on 8/27/24 and discharged on 10/3/24. A treatment plan was completed on 8/27/24. The next update was due no later than 9/27/24; however, there was no update documented in the record.
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Plan of Correction
All client treatment plans have been updated as of 12/2/24. There have been new counselors assigned to the client caseloads, therefore ensuring treatment plans are updated before or by the scheduled update date. Clinical staff has received in house training on treatment planning, progress notes and group notes. SUD Program Director will ensure that there is continues in-house trainings in the clinical areas. Weekly chart audits will continue to ensure timely documentation and updates. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes with information relative to the client's involvement with the project in six of six records reviewed.
Client # 1 was admitted on 9/18/24 and was still a client at the time of the investigation. All group progress notes containing data on the session, an assessment of the client's participation and a plan for the client was observed to have the same plan on every group progress note.
Client # 2 was admitted on 9/16/24 and was still a client at the time of the investigation. All group progress notes containing data on the session, an assessment of the client's participation and a plan for the client was observed to have the same plan on every group progress note.
Client # 3 was admitted 9/11/24 and was still a client at the time of the investigation. All group progress notes containing data on the session, an assessment of the client's participation and a plan for the client was observed to have the same plan on every group progress note.
Client # 4 was admitted on 8/27/24 and discharged on 10/3/24. All group progress notes containing data on the session, an assessment of the client's participation and a plan for the client was observed to have the same plan on every group progress note.
Client # 5 was admitted on 7/18/24 and discharged on 9/14/24. All group progress notes containing data on the session, an assessment of the client's participation and a plan for the client was observed to have the same plan on every group progress note.
Client # 6 was admitted on 7/12/24 and discharged on 8/13/24. All group progress notes containing data on the session, an assessment of the client's participation and a plan for the client was observed to have the same plan on every group progress note.
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Plan of Correction
Clinical staff have received training on 12/6/24 on documentation and expectations. Counselors will begin individualizing all group progress note plan. This will be evidenced by weekly chart audits. SUD Program Director will work individually with clinical staff to provide feedback and necessary training. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a physical plant inspection conducted on November 21, 2024, the facility failed to follow their written policy and procedures for receiving, storing and preserving food.
Per the SACA Food Contribution/Meal Policy - Food may be purchased, donated by local businesses, food banks, and prepared by SERV Safe certified cooks at the main Center. SACA may rely on partnerships with grocery stores, farms, and charitable organizations for food supplies. SACA will ensure food is safe and consumable - no damaged packaging, spoiled for, or expired items. Inspection and Sorting - all donated food should be inspected prior to accepting. Check for expiration dates to ensure food is still safe to eat.
The dry food storage area in the basement contained a crate of San Giorgio pasta with a best if used by date of November 2022 and multiple containers of Quaker Oats with a best before date of July 2024.
The kitchen refrigerator contained two Tuscan Garden Light Raspberry Vinaigrette salad dressings with an expiration date of 12/7/23.
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Plan of Correction
On 11/29/24 kitchen refrigerator was cleaned out and all expired items were discarded. The dry pantry area was inspected and all expired items were disposed of. An inventory check list has been created for the residential aides to review, subtract and add any items utilized or received. The staff will be responsible for completing the form and rotating inventory accordingly as well as discarding any items that are expired. Staff will complete this form twice per week and sign they have completed. SUD Program Director will review the inventory form weekly to ensure this procedure is followed. |