INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 21, 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 of SACA Drug and Alcohol Program 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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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 four 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 name of the person, agency or organization to whom disclosure is made.
Client # 2 was admitted on September 25, 2020 and was discharged on December 18, 2020. An informed and voluntary consent form dated September 25, 2020 did not provide the name of the person, agency or organization to whom disclosure is made.
Client # 4 was admitted on September 22, 2020 and was still active at the time of the inspection. An informed and voluntary consent form dated October 1, 2020 did not provide the name of the person, agency or organization to whom disclosure is made. Also, in the medical record, three informed and voluntary consent forms dated October 12, 2020 did not provide the name of the person, agency or organization to whom disclosure is made.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020. In the medical record, three informed and voluntary consent forms dated July 30, 2020 did not provide the name of the person, agency or organization to whom disclosure is made.
Client # 7 was admitted on August 25, 2020 and was discharged on September 9, 2020. Three informed and voluntary consent forms dated August 25, 2020 did not provide the name of the person, agency or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 23,2020 Director retrained the counselors and case manager on the process of completing the consents. director also gave copies of mock correctly completed consents as a guide. Director will audit random charts weekly for 3 months and biweekly for 6 months following to ensure compliance |
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 two of eight client records reviewed, the facility failed to include the specific information to be disclosed in client record #7, 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 # 8.
Client # 7 was admitted on August 25, 20920 and was discharged on September 9, 2020. An informed and voluntary consent from the client for the disclosure of information dated August 25, 2020 to an unknown recipient did not provide the specific information to be released.
Client # 8 was admitted on July 27, 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 probation officer dated July 27, 2020 allowed for the release of "ongoing treatment needs, participation in family education groups, participation in counseling sessions".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 23,2020 Director retrained the counselors and case manager on the process of completing the consents. director also gave copies of mock correctly completed consents as a guide. Director will audit random charts weekly for 3 months and biweekly for 6 months following to ensure compliance
For clients still present in treatment corrections will be made to consents or new consents completed |
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 four of eight client records reviewed, the facility failed obtain an informed and voluntary consent from the client for the disclosure of information to include purpose of disclosure.
Client # 2 was admitted on September 25, 2020 and was discharged on December 18, 2020. An informed and voluntary consent form dated September 25, 2020 did not provide the purpose of disclosure.
Client # 4 was admitted on September 22, 2020 and was still active at the time of the inspection. An informed and voluntary consent form dated October 1, 2020 did not provide the purpose of disclosure. Also, in the medical record, an informed and voluntary consent form dated October 12, 2020 did not provide the purpose of disclosure.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020. In the medical record, an informed and voluntary consent form dated July 30, 2020 did not provide the purpose of disclosure.
Client # 7 was admitted on August 25, 2020 and was discharged on September 9, 2020. An informed and voluntary consent form dated August 25, 2020 did not provide the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 23,2020 Director retrained the counselors and case manager on the process of completing the consents. director also gave copies of mock correctly completed consents as a guide. Director will audit random charts weekly for 3 months and biweekly for 6 months following to ensure compliance
Active client records will be corrected or when necessary a new consent completed to meet regulations |
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 four client records reviewed, the facility failed to provide an informed and voluntary consent from the client for the disclosure of information to include the dated signature of the client.
Client # 4 was admitted on September 22, 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 by the witness October 1, 2020 to an unknown source was not dated by the client. Also, three informed and voluntary consent forms the client for the disclosure of information in the medical record dated by the witness for October 12, 2020 did not include a date by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 23,2020 Director retrained the counselors and case manager on the process of completing the consents. director also gave copies of mock correctly completed consents as a guide. Director will audit random charts weekly for 3 months and biweekly for 6 months following to ensure compliance
Active records will have consents corrected and if necessary new consents will be completed to meet standards |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on three 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 date, event or condition upon which the consent will expire.
Client # 4 was admitted on September 22, 2020 and was still active at the time of the inspection. An informed and voluntary consent form dated October 1, 2020 did not provide the the date, event or condition upon which the consent will expire. Also, in the medical record, three informed and voluntary consent forms dated October 12, 2020 did not provide the date, event or condition upon which the consent will expire.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020. In the medical record, three informed and voluntary consent forms dated July 30, 2020 did not provide the date, event or condition upon which the consent will expire.
Client # 7 was admitted on August 25, 2020 and was discharged on September 9, 2020. Two informed and voluntary consent forms dated August 25, 2020 did not provide the date, event or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 23,2020 Director retrained the counselors and case manager as well as the medical admission staff on the process of completing the consents. Director also gave copies of mock correctly completed consents as a guide. Director will audit random charts weekly for 3 months and biweekly for 6 months following to ensure compliance
Active charts will have consents corrected or a new consent completed to meet regulations |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on three 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 documentation that a copy of a client consent shall be offered to the client.
Client # 4 was admitted on September 22, 2020 and was still active at the time of the inspection. An informed and voluntary consent form dated October 1, 2020 did not provide documentation that a copy of a client consent shall be offered to the client. Also, in the medical record, three informed and voluntary consent forms dated October 12, 2020 did not provide documentation that a copy of a client consent shall be offered to the client.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020. In the medical record, three informed and voluntary consent forms dated July 30, 2020 did not provide documentation that a copy of a client consent shall be offered to the client.
Client # 7 was admitted on August 25, 2020 and was discharged on September 9, 2020. An informed and voluntary consent form dated August 25, 2020 did not provide documentation that a copy of a client consent shall be offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On December 23,2020 Director retrained the counselors and case manager on the process of completing the consents. director also gave copies of mock correctly completed consents as a guide. Director will audit random charts weekly for 3 months and biweekly for 6 months following to ensure compliance
Active charts will have consents corrected or a new consent completed to meet regulations
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715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on one of eight client records reviewed, the facility failed to provide documentation prior to the adminstration of an agent verifying that the individual has reached 18 years of age.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with medical staff on 12/23/2020 and advised staff that all clients in MAT will have identification uploaded into electronic medical records for permanent record retention. Process to be completed for all current records to reach compliance and all future admissions to the program beginning on January 7 2021 and remain for all clients going forward
case Manager will be responsible with director doing completing random audits for compliance |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on one of eight client records reviewed, the facility failed to provide documentation prior to the adminstration of an agent verifying the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with medical staff on 12/23/2020 and advised staff that all clients in MAT will have identification uploaded into electronic medical records for permanent record retention. Process to be completed for all current records to reach compliance and all future admissions to the program beginning on January 7 2021 and remain for all clients going forward. The office manager will pull all current client files to ensure that all current clients have photo identification and if they don't she will add them and in future charts they will have photo taken and/or identifications in chart Records will be randomly audited for the next 6 months biweekly then monthly going forward |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on one of eight client records reviewed, the facility failed to provide documentation of an onsite a photograph of each patient which includes the patient 's name and birth date.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with medical staff on 12/23/2020 and advised staff that all clients in MAT will have a picture uploaded into electronic medical records for permanent record retention, along with a copy in the client chart Process to be completed for all current records to reach compliance and all future admissions to the program beginning on January 7 2021 and remain for all clients going forward.
Director to do random chart audits weekly for the next 6 months for compliance |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on one of eight client records reviewed, the facility failed to provide documentation of an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020. There was no documentation of an initial drug-screening urinalysis or a random urinalysis at least monthly thereafter in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with staff on 12/23/2020 and discussed the need to keep all records of drug screens in the paper chart as well as uploading a permanent cop to the electronic medical records for retention purposes. Director will audit charts weekly for 6 months then biweekly for the next 6 months. Staff will begin process on January 7th off auditing charts to ensure they are up to date and all new clients will have information readily available for review. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on three of eight client records reviewed, the facility failed to provide a preliminary treatment and rehabilitation plan in accordance to the facilities policy and procedure manual which indicates to be completed on the first counseling session.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020. There was not a preliminary treatment and rehabilitation plan documented in the client record on the first counseling session.
Client # 7 was admitted on August 25, 2020 and was discharged on September 9, 2020. There was not a preliminary treatment and rehabilitation plan documented in the client record on the first counseling session.
Client # 8 was admitted on July 27, 2020 and was still active at the time of the inspection. There was not a preliminary treatment and rehabilitation plan documented in the client record on the first counseling session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with therapists on 12/23/2020 regarding the process for admission treatment plans both initial and updates. the staff was given a copy of the regulation. Director will audit charts weekly for 3 months and biweekly for 6 months thereafter to ensure compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on three of eight client records reviewed, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include follow-up information in accordance with the facilities policy and procedure manual that indicates a letter will be sent to the client.
Client # 1 was admitted on September 30, 2020 and was discharged on November 13, 2020. There was no documentation of a follow-up in the client record. The letter that is sent to the client was blank in the client record.
Client # 5 was admitted on June 16, 2020 and was discharged on September 2, 2020. There was no documentation of a follow-up in the client record. The letter that is sent to the client was blank in the client record.
Client # 7 was admitted on August 25, 2020 and was discharged on September 9, 2020. There was no documentation of a follow-up in the client record. The letter that is sent to the client was blank in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 12/23/2020 director met with case manager and the therapists regarding the regulation on follow up. Case Manager will send out letters to clients discharge in the last 30 days and therapists will complete the letters for follow up to the client and make a copy for retention. If the client returns letter it will be filed in the chart. Process begins on 1/4/2021.Case Manager will audit charts weekly and director will audit biweekly for compliance |