INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion was found 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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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 one of six personnel records reviewed, the facility failed to ensure that all 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 within the regulatory time frame for support staff.
Employee # 6 was hired as a driver on November 17, 2014 and was still in this position at the time of the inspection. Employee # 6 did not 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 at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 7, 2020 inspection.
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Plan of Correction
The clinical supervisor will schedule this individual for training in first available DDAP approved training not to exceed 6 months from this date based on DDAP schedule to COVID restrictions. Clinical Supervisor will schedule all new staff to complete this training and present information to director for ALL new hires within 30 days of hire going forward. |
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 the facilities fire drill log, there was no documentation of a fire drill the month of January 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will establish and maintain record of unannounced fire drills. Documentation was found in 2019 paperwork which had been sent to the state during last audit. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom disclosure is made.
Client #4 was admitted on November 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 2, 2020 did not include the name of the person, agency or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from January 7, 2020 inspection.
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Plan of Correction
The active client was asked to review and sign the consent once completed. The clinical supervisor/lead counselor will audit all admission charts within 24 hours of admission to ensure completion of consents are consistent with regulations. Random audits will also be conducted weekly by director for the next 3 months and then bi-weekly for another 3 months at which time random audits will occur. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on three of seven client records reviewed, the facility failed to include the specific information to be disclosed in client record #4, and failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 2 and #7.
Client # 2 was admitted on November 9, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record to a municipality dated December 15, 2020 allowed for the release of "legal".
Client #4 was admitted on November 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 19, 2020 did not include the specific information disclosed.
Client # 7 was admitted on December 11, 2019 and discharged on January 28, 2020. An informed and voluntary consent from the client for the disclosure of information contained in the client record to a probation officer dated December 11, 20219 allowed for the release of "ongoing treatment needs, participation in family education groups, hospitalization, and death or injury".
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 7, 2020, and the February 8, 2019 inspection.
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Plan of Correction
Active client charts were pulled and consents updated by intake worker and client.
Intake worker was retrained in documenting disclosure from legal to continuity of care when it applied.
Client named his PO as only living person that he had trusted contact with in case of emergency. He was advised that we would need to remove that consent based upon the licensing review.
The clinical supervisor/lead counselor will audit all admission charts within 24 hours of admission to ensure completion of consents are consistent with regulations. Random audits will also be conducted weekly by director for the next 3 months and then bi-weekly for another 3 months at which time random audits will occur.
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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 seven 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 disclosure.
Client #4 was admitted on November 2, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 19, 2020 did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from January 7, 2020 inspection.
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Plan of Correction
Active client chart was pulled and updated by intake worker.
Intake worker was retrained and will be responsible to complete these forms going further. Clinical supervisor will audit charts weekly for the next 3 months and monthly for the next 3 months. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on seven of seven client records reviewed, the facility failed to document written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Client # 1 was admitted on September 29, 2020 and was still active at the time of the inspection. The client rights acknowledgement form provided to the client did not include the verbiage "age, creed, ethnicity, national origin, marital status, or sexual orientation".
Client # 2 was admitted on November 9, 2020 and was still active at the time of the inspection. The client rights acknowledgement form provided to the client did not include the verbiage "age, creed, ethnicity, national origin, marital status, or sexual orientation".
Client # 3 was admitted on November 24, 2020 and was still active at the time of the inspection. The client rights acknowledgement form provided to the client did not include the verbiage "age, creed, ethnicity, national origin, marital status, or sexual orientation".
Client # 4 was admitted on November 2, 2020 and was still active at the time of the inspection. The client rights acknowledgement form provided to the client did not include the verbiage "age, creed, ethnicity, national origin, marital status, or sexual orientation".
Client # 5 was admitted on February 3, 2020 and was discharged on March 24, 2020. The client rights acknowledgement form provided to the client did not include the verbiage "age, creed, ethnicity, national origin, marital status, or sexual orientation".
Client # 6 was admitted on July 21, 2020 and was discharged on September 3, 2020. The client rights acknowledgement form provided to the client did not include the verbiage "age, creed, ethnicity, national origin, marital status, or sexual orientation".
Client # 7 was admitted on December 11, 2019 and was discharged on January 28, 2020. The client rights acknowledgement form provided to the client did not include the verbiage "age, creed, ethnicity, national origin, marital status, or sexual orientation".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The master chart was update (again) and the active client charts were pulled and updated with correct language of age, creed, ethnicity, national origin, marital status, or sexual orientation.
Intake worker will be responsible to review all blank charts prior to admission and clinical supervisor will audit all new admission charts within 24 hours to ensure that the paperwork is correct for the next 6 months. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a complete record of service for clients # 1, 2, and 6.
Client # 1 was admitted on September 29, 2020 and was still active at the time of the inspection. Progress notes dated November 29, November 22, and November 8, 2020 were not documented on the clients record of service.
Client # 2 was admitted on November 9, 2020 and was still active at the time of the inspection. Progress notes dated December 15, December 10, December 2, November 24, November 14, and November 11, 2020 were not documented on the clients record of service.
Client # 6 was admitted on July 21, 2020 and was discharged on September 3, 2020. Progress notes dated August 21, August 13, and July 29, 2020 were not documented on the clients record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor met with counseling staff to explain the need of both record of service and the progress note. Clinical supervisor will complete random chart audits for the next 6 months weekly and then biweekly going forward.
Clinical supervisor advised counseling team to self audit to ensure compliance |