INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPANISH AMERICAN CIVIC ASSOCIATION FOR EQUALITY, INC was found not to be 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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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training to perform assigned tasks during emergencies.
Employee #2 was hired on May 23, 2023 for the position of counselor and was still employed at the time of the inspection. No training was documented.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
The Project Director will develop a staff record check-list that will be included in the staff records of all employees. This checklist will include the necessary DDAP trainings to ensure compliance. The staff member's date of employment will determine the customization of this checklist, which is defined by a specific timeline. An anticipated completion date will be assigned to each item.
The Project Director will collaborate with staff members to finalize all items on the checklist.
The Director of Quality, Control & Compliance will conduct a random audit of staff records to guarantee compliance.
Employee #2 Completed training per reg 705.10 (d)(3) with project director on 05/16/2024. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from January, 2024 through April, 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months as the last sleeping drill occured prior to March, 2023. There is no record of a sleep fire drill being completed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Sleep fire drill conducted/completed on 05/16/24, project director will work with director of quality, control and compliance to ensure sleep fire drills are conducted every 6 months per reg 705.10 (d)(5). |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based upon a review of the policy and procedure manual and discussion with facility staff, the facility failed to prepare, annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Completed
The onsite draft manual has been replaced with an updated policy and procedure manual that includes signature. Project Director and Director of Quality, Control and Compliance will ensure annual review of the P&P manual and compliance of reg 709.23. |
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 a review of the facility's policy and procedures manual, the facility failed to adopt a written procedures for the management of treatment/rehabilitation services for clients.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Completed. Policy & Procedure Manual updated to include written plan for coordination of client treatment and rehabilitation services according to reg 709.24 (a)(3). |
709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt written procedures for referral outlining cooperation with other services providers including, but not limited to, provision for access to emergency services.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Completed. Policy & Procedure Manual updated to include written plan for referral outlining cooperation with other service providers including, provision for access to emergency services according to reg 709.24 (a)(4). |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to submit rebuttal data or memoranda to their own records.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Completed. The following statement was added to the client rights policy to ensure compliance with reg 709.30.(6): "Clients have the right to submit rebuttal data or memoranda to their own records." |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered in three out of seven applicable records.
Client #2 was admitted on March 4, 2024 and was still active at the time of the inspection. He was prescribed Varenaline .5mg 1 tab two times a day. There was no documentation of the medication being administered twice a day or the reason not administered on March 7, 8 9, 12, 15,16,18 and April 2 and 3, 2024. He was also prescribed Bupropion HCL ER(XL) 150 mg 1 time daily. There was no documentation of the medication being administered or the reason not administered on March 10, 11, 18-30 and April 8- May 4, 2024
Client #3 was admitted on March 7, 2024 and was still active at the time of the inspection. He was prescribed Amoxicillin 500mg 1 capsule, 3 times a day. There was no documentation of the medication being administered as prescribed or the reason not administered on March 26-30 and April 6-8, 2024. He was also prescribed Vitamin D# 50 MCG (1,000 UT) one time daily. There was no documentation of the medication being administered as prescribed or the reason not administered on March 12-21, 2024.
Client #5 was admitted on March 11, 2024 and was still active at the time of the inspection. He was prescribed Levetiracetam 250 mg tab two times a day. There was no documentation of the medication being administered as prescribed or the reason not administered on March 11-13, 19, 23, 24, 29, and April 2 and 3, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 21, 2023 and the January 10, 2024 licensing inspection.
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Plan of Correction
The Project Director will conduct a daily audit of the client's MAR commencing on 06/10/2024. The purpose of this audit is to verify the medication is administered to the client and to ensure that appropriate documentation is completed. This procedure will be ongoing and in the absence of the Project Director, the Nurse on staff is responsible for reviewing the medication log.
Director of Quality Control & Compliance will also perform random, MARS audit to prevent reoccurrence in the future.
The date and the signature/initial of the Project Director or the Nurse will be required as evidence of the review.
Project Director will collaborate with the Nurse to conduct an on-site audit to verify the handling, storage, and administration of medication in accordance with the medication policy and procedure. This audit will take place on 06/05/2024 and has been completed.
The findings from the onsite audit conducted by the LPN led to the following conclusions:
The Nurse will be tasked with conducting a comprehensive medication training session for the staff. This session will include several areas, such as a thorough review of our medication policies and procedures, medication administration (including self-administration by the client), medication documentation requirements, and proper medication storage practices.
Nurse will continue to audit medication inventory on a weekly basis starting 06/14/2024.
Nurse will will share weekly findings with Director of Quality, Control & Compliance.
Written policy and procedures regarding reg 709.32 (c)(1)(i)-(ii) is complete.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to have written policy and procedures to include the inspection of storage areas that ensure compliance with laws. The policy and procedures did not include what is to be verified through the inspection, storage of disinfectants and external use drugs, drugs requiring special conditions, removal of outdated drugs and copies of drug-related regulations availability in appropriate areas.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Written policy and procedures regarding reg 709.32 (c)(3)(i)-(v) is complete.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to have written policy and procedures to include the methods for control and accountability of drugs including who is authorized to remove the drug and a system for recording drugs.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Written policy and procedures regarding reg 709.32 (c)(4)(i)-(ii) is complete.
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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to have written policy and procedures to include the security of drugs including loss, theft or misuse of drugs.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Written policy and procedures regarding reg 709.32 (c)(5) is complete.
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709.54(a)(4) LICENSURE Safety/sanitation
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:
(4) Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Written policy and procedures regarding reg 709.54 (a)(4) is complete.
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709.54(a)(5) LICENSURE Personal hygiene
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:
(5) Personal hygiene for those in food preparation areas.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include personal hygiene for those in food preparation areas.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
Written policy and procedures regarding reg 709.54 (a)(5) is complete.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
709.17(a)(3) - Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for medication administration records were submitted and approved by the Department for the March 21, 2023 and January 10, 2024 annual licensing inspections. Treatment plan updates was again found to be a deficiency in the May 15, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The prior Plan of Correction was prepared by the former project director, who is no longer with the organization.
To ensure compliance, the existing Project Director has collaborated with the Director of Quality, Control & Compliance and an LPN to ensure that all POC's are adhered to.
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