INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16 through 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion 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 and a plan of correction is due on January 13, 2009.
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Plan of Correction
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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 the review of facility administrative records, the facility failed to document fire drills in four of the nine months reviewed.
The findings include:
Fire drill documentation was reviewed on December 17, 2008. The facility did not document fire drills in March, April, May and June of 2008.
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Plan of Correction
Regular unannounced monthly fire drills resumed July 2008 will arrival of new facility director.
Drills documented in fire safety log by House Manager and reported to Operations Supervisor.
Facility director monitors fire safety by checking log on a weekly basis and fire drills reported at weekly staff meeting.. Facility director to verify fire drills by signing off on monthly log. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of facility records, the facility failed to document that the governing body was presented the policy and procedures manual on an annual basis.
The findings include:
Facility administrative records were reviewed on December 18, 2008. The facility had no documentation that the policy and procedures manual was presented to the governing body for the 08-09 fiscal year.
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Plan of Correction
Current facility director to present policy and procedures manual to the governing body for the 08-09 fiscal year on 1/28/2009. Head of governing board will verify by signing documentation of presentation. Documentation to be included in manual.
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of facility records, the facility failed to present goals and objectives to the governing body on an annual basis.
The Findings include:
Facility administrative records were reviewed on December 16, 2008. The facility had no documentation that goals and objectives for the 08-09 fiscal year were presented to the governing body.
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Plan of Correction
Current project director will present a modified version of goals and objectives for 08-09 fiscal year on January 28, 2009. Included will be a review of past 6 months. Head of governing body will verify by signing documentation of the presentation.
Documentation to be included in 2008-2009 policies and procedures manual. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of facility records, the facility failed to document a performance report summarizing progress towards meeting goals and objectives.
The findings include:
Facility administrative records were reviewed on December 16, 2008. The facility had no documentation of a report summarizing the progress towards meeting goals and objectives for the 07-08 fiscal year.
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Plan of Correction
Previous project director failed to submit goals and objectives for the 07-08 fiscal year. Current project director will present modified version of 07-08 goals and objectives including a performance review of prior 6 months to governing board on 1/28/2009. Head of board will verify presentation by signing documentation. Documentaion to be kept in policies and procedures manual for 08-09. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document consents to release information in three of three client records.
The findings include:
Three client records were reviewed on December 17, 2008. Information was released to a pharmacy in all three records without a consent to release information being completed. This occurred in client records # 1, 2 and 3.
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Plan of Correction
Project director informed all staff involved of lack of consents in cited client records on December 17, 2008.
Project director and Clincal Supervisor check all presented charts at Weekly Case Review
Project director to hold on-site training on Confidentiality in Documentation with all staff involved with client records on January 27, 2009. |
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 shall be in writing and shall 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 the review of client records, the facility failed to document the name of the person, agency or organization to whom disclosure is made in one of three client records.
The findings include:
Three client records were reviewed on December 17, 2008. Consents to release information were required in three of three client records. The facility did not document the name of the person, agency or organization to whom disclosure was made on any consent to release information in client record # 3.
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Plan of Correction
Project director informed all staff involved of lack of specificity in consents in cited client record on December 17, 2008. Project director and Clincal Supervisor check all presented charts at Weekly Case Review .
Project director to hold on-site training on Confidentiality in Documentation with all staff involved with client records on January 27, 2009. |