INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 20-21, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Nuestra Clinica Rehabilitacion 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on November 20, 2024, the facility failed to maintain its grounds in good repair at all times for the safety and well-being of residents, employees and visitors.
Window blind slats were broken and missing in the following client bedrooms: first floor room B-1 and B-2, second floor room C, third floor first room on the left with no identifying letter, room D and room F.
Ceiling lights were missing covers on the third floor, first room on the left with no identifying letter, room D and room F.
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Plan of Correction
We are currently in the process of renovating the building. We will temporary close the clinic from 1/2/25 until 3/2/25 for painting, flooring and general building maintenance. During the renovation process we will be ensuring that all blinds have been replaced as well as lighting fixtures. All rooms will be labeled with respective room number/letter. CEO as well as SACA Development/maintenance will inspect prior to re-opening the facility. SUD Program Director will then complete weekly inspections to ensure all areas of the physical facility are well maintained. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on staff interviews and a physical plant inspection conducted on November 20, 2024, the facility failed to ensure privacy to that counseling sessions cannot be seen or heard outside the counseling room.
Cameras, with audio capabilities, were observed in the area where group sessions are conducted.
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Plan of Correction
On 11/21/24 immediately after the auditor reported the deficiency. Security company was called out to turn off the bedroom and group room cameras/audio. On 11/23/24 the security company came out to the clinic location and physically removed the cameras from the bedrooms. The group room camera remains in place as this is also considered a common area, with the exception of having the audio turned off and the camera covered during groups. SUD Program Director will ensure that this process is followed during all group meetings. |
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
On Monday 11/25/24, after the audit, the administrative team met and it was decided that contracted consultant will report to each individual facility and audit the client charts on site. SUD Program Director will ensure this process is followed during said chart reviews. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of employee files, along with staff and client interviews, the facility failed to follow its Staff Code of Ethics and Conduct.
Per the Staff Code of Ethics and Conduct, employees are to treat others with dignity and respect at all times. SACA will not tolerate discrimination, harassment or any behavior or language that is abusive, offensive or unwelcome.
A supervisory session was held for an employee concerning their interactions with clients that are not aligned with the Staff Code of Ethics and Conduct. During staff and client interviews, it was reported that this employee does not treat clients respectfully and will threaten them with discharge and incarceration.
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Plan of Correction
All staff have been given the code of ethics for review and signature of acknowledgement, including the staff member in question. The staff member in question has also been scheduled for additional trainings on Ethics and code of conduct. SUD Program Director will ensure the are completed by 12/30/24. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on November 20, 2024, the facility failed to secure client records within locked storage containers.
Client files were observed in an unlocked cabinet in the office where the House Manager Supervisor is located and where the investigators were stationed during the investigation.
Client files were observed in the basement in an unlocked room with the door open. The files were found in banker boxes stored on shelves. There were four cabinets in the room that also contained client files. 3 of these cabinets had no lock and one cabinet, with a lock, was unlocked. The basement is utilized for food storage and client laundry.
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Plan of Correction
All files have been locked and secured immediately after the audit. Staff responsible for filing closed charts in the basement has been retrained on the importance of keeping these files locked and secured. Prior to the end of shift responsible staff members will ensure all file rooms and cabinets are locked and secured. SUD Program Director will conduct random inspections to ensure this process is followed at all times. |
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
Based on staff interviews and a physical plant inspection conducted on November 20, 2024, the facility failed to retain civil rights and liberties, depriving clients of their civil rights solely by reason of treatment.
Cameras, with audio capabilities, were observed throughout the facility. This includes in every client bedroom, where there is a reasonable expectation of privacy, and in the medical office where assessments and medical concerns are discussed. Also, it was reported that staff monitor the camera footage while working and during times they are not working.
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Plan of Correction
On 11/21/24 immediately after the auditor reported the deficiency. Security company was called out to turn off the bedroom and group room cameras/audio. On 11/23/24 the security company came out to the clinic location and physically removed the cameras from the bedrooms. The group room camera remains in place as this is also considered a common area, with the exception of having the audio turned off and the camera covered during groups. SUD Program Director will ensure that this process is followed during all group meetings. Staff member who had access to the cameras when off duty no longer has access.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of incident reports, the facility failed to inform the Department of an unusual incident within the required three days.
An event occurred on October 4, 2024, requiring the presence of ambulance personnel.
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Plan of Correction
All staff have been re-educated on the process for incident report, as well as the policy for unusual incident reports. acknowledgement page has been signed by all staff members. All incident reports will immediately be completed and SUD Director will be notified immediately. SUD Director and or Quality and Compliance Officer will submit the incident report to MCO as well as DDAP. SUD Director will review incident report binder weekly as well to ensure no incident reports are missed. Effective 12/10/24. |
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 seven of seven records reviewed.
Client # 1 was admitted on 2/20/24 and discharged on 6/12/24. 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 # 2 was admitted on 9/24/24 and discharged on 10/7/24. 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 # 3 was admitted on 8/2/24 and discharged on 10/8/24. 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 # 4 was admitted on 7/26/24 and discharged on 10/18/24. 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 9/25/24 and was still active 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 # 6 was admitted on 10/23/24 and was still active 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 # 5 was admitted on 11/6/24 and was still active 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.
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Plan of Correction
All clinical staff received training on 12/6/24 on treatment plans, progress notes, and group notes. Clinical team will begin individualizing all group progress notes. They will also begin adding follow up dates to revisit the subject. Contracted consultant will review charts weekly to confirm this area has improved. SUD will meet with consultant for feedback on progress of said documentation. |
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 20, 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, foodbanks, 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 food, 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.
A case of unsweetened applesauce was observed in the refrigerator in the basement. This applesauce was stamped best if used by October 15, 2023.
Mustard was observed in the refrigerator in the kitchen. This mustard had a best by date of April 23, 2024.
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Plan of Correction
All expired items have been discarded. An inventory check off list has been created for all residential aides to utilize during their shifts for rotating inventory. Any expired items will be immediately discarded and any soon to expire items will be brought upstairs for rapid consumption or to be discarded. Residential Aide Supervisor will ensure this task is completed weekly. SUD Program Director will then ensure the supervisor has been following up on this. |