INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on January 7, 2020. Based on the findings of the on-site inspection, Nuestra Clinica Rehabilitacion was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
|
Observations
The facility failed to provide a positive assessment of the counselor assistant's individual skill level, in addition to training prior to assignment of a full caseload
Staff # 5 was hired on November 11, 2019 as a counselor assistant. Staff #5 did not have a positive assessment prior to assignment of a full caseload.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The counselor assistant was a rehire and had a positive assessment in his file from 12/10/2018 that was faxed from the business office. He was rehired on 11/11/2019. The director will ensure that all information is copied into employee file on site and that the clinical supervisor has access to files. Each employee will be reviewed semi annually to ensure compliance |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
The facility failed to provide direct observation by a trained counselor or clinical supervisor for a counselor assistant with a high school diploma or GED for the first 3 months of employment. The facility also failed to allow the counselor assistant to counsel clients only under the close supervision of a lead counselor or a clinical supervisor for the next 9 months.
Staff # 4 was hired on July 16, 2019 as a Counselor Assistant having a High School Diploma. Staff #4 received direct supervision for .5 hour on August 8, 2019. Staff #4 had .5 hours of indirect supervision on September 4, 2019, October 2, 2019, November 4, 2019, December 4, 2019 and January 4, 2020. Staff #4 had been assigned a full caseload per the Staffing Requirement Facility Summary Report.
Staff #5 was hired as a Counselor Assistant with qualification of a GED on November 11, 2019. Staff #5 received .5 hours of indirect supervision on December 11, 2019. Staff #5 had been assigned a full caseload per the Staffing Requirement Facility Summary Report.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselor assistant had 1 hour of group supervised and one hour of individual supervision. All group notes signed by supervisor that attended group. The director will pull all supervision notes going forward and place them clearly in a binder for review. 2 hours of supervision weekly including direct supervision for the first 3 months and close supervision for the next 9 months. Going forward all counselor assistants will have direct/close supervision documented and placed on file for review. Effective immediately
|
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.
|
Observations
The facility failed to ensure that staff persons 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.
Staff # 15 was hired on November 14, 2014 as a driver and should have had the HIV/AIDS and TB/STD trainings no later than November 14, 2016. Staff # 15 did not have the HIV/AIDS and TB/STD trainings documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff #15 was sent to a training for HIV/STD/TB on January 23, 2020.
Employee files will be reviewed quarterly for compliance by clinical supervisor. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
The project failed to comply with the client/staff and client/counselor ratios) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client. Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation) serving adult clients shall have one FTE counselor for every eight clients.
The project had one FTE counselor for every 9 clients.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
The staff full time counselors will have 8 clients and the clinical supervisor will assign the case load based upon the FTE regulation. Clinical supervisor will monitor weekly and the director will monitor monthly for the next year |
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.
|
Observations
During a review of client records on January 7, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in 4 out of 7 client records. The consent must be in writing and include, but not be limited to the name of the person, agency or organization to whom disclosure is made.
Client #1 was admitted on November 26, 2019 and was current at the time of the inspection. Client #1 had an authorization to a primary care physician, a court legal system and a treatment facility that was signed and dated and failed to have the name of a person, agency or organization to whom disclosure was to be made.
Client # 2 was admitted on November 17, 2019 and was current at the time of the inspection. Client #2 had an authorization to a primary care physician, a court legal system and a treatment facility that was signed and dated and failed to have the name of a person, agency or organization to whom disclosure was to be made.
Client # 3 was admitted on October 31, 2019 and was current at the time of the inspection. Client #3 had an authorization to a general consent that was signed and dated and failed to have the name of a person, agency or organization to whom disclosure was to be made.
Client # 4 was admitted on November 20, 2019 and was current at the time of the inspection. Client #4 had an authorization to a family member that was signed and dated and failed to have the name of a person, agency or organization to whom disclosure was to be made.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
The front desk staff (intake coordinator) along with counselors were retrained on the consent process and the need to complete all information on 2/3/2020.
The clinical supervisor will complete and document weekly random chart audits. The director will completed monthly chart audits for the next 6 months' |
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.
|
Observations
During a review of client records on January 7, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one out of seven client records. The consent must be in writing and include, but not be limited to the specific information disclosed.
Client #3 was admitted on October 31, 2019 and was current at the time of the inspection. Client #3 had an authorization to a general consent that was signed and dated and failed to have the specific information disclosed.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
Staff was retrained on February 3, 2020. Clinical supervisor will complete random chart audits weekly for the next 6 months, then bi-weekly for a year. The director will complete monthly chart audits.
refresher trainings will be held every 6 months to address turn around. |
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.
|
Observations
During a review of client records on January 7, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in four out of seven client records. The consent must be in writing and include, but not be limited to the purpose of disclosure.
Client #1 was admitted on November 26, 2019 and was current at the time of the inspection. Client #1 had an authorization to a funding source that was signed and dated and failed to have the purpose of disclosure.
Client #2 was admitted on November 17, 2019 and was current at the time of the inspection. Client #2 had an authorization to a primary care physician, a general consent and a legal entity that was signed and dated and failed to have the purpose of disclosure.
Client #3 was admitted on October 31, 2019 and was current at the time of the inspection. Client #3 had an authorization to a funding source and a general consent that was signed and dated and failed to have the purpose of disclosure.
Client #4 was admitted on November 20, 2019 and was current at the time of the inspection. Client #4 had an authorization to a funding source that was signed and dated and failed to have the purpose of disclosure.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
Staff was retrained on February 3, 2020. Clinical supervisor will complete random chart audits weekly for the next 6 months, then bi-weekly for a year. The director will complete monthly chart audits.
refresher trainings will be held every 6 months to address turn around. |
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.
|
Observations
During a review of client records on January 7, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in three out of seven client records. The consent must be in writing and include, but not be limited to date, event or condition upon which the consent will expire.
Client #1 was admitted on November 26, 2019 and was current at the time of the inspection. Client #1 had an authorization to an emergency contact, two social service agencies, a family member, two funding sources, two pharmacies, a legal entity, and a treatment facility that was signed and dated but did not include the date, event or condition upon which the consent will expire.
Client #2 was admitted on November 17, 2019 and was current at the time of the inspection. Client #2 had an authorization to two legal entities that was signed and dated but did not include the date, event or condition upon which the consent will expire.
Client #3 was admitted on October 31, 2019 and was current at the time of the inspection. Client #3 had an authorization to a general consent that was signed and dated but did not include the date, event or condition upon which the consent will expire.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
Staff was retrained on February 3, 2020. Clinical supervisor will complete random chart audits weekly for the next 6 months, then bi-weekly for a year. The director will complete monthly chart audits.
refresher trainings will be held every 6 months to address turn around. |
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.
|
Observations
During a review of client records on January 7, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in five out of seven client records. The consent must be in writing and include, but not be limited to whether a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Client #1 was admitted on November 26, 2019 and was current at the time of the inspection. Client #1 had an authorization to an emergency contact, two social service agencies, two pharmacy services, three funding sources, a family member, two legal entities, and a treatment facility that were signed and dated and failed to indicate whether a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Client #2 was admitted on November 17, 2019 and was current at the time of the inspection. Client #2 had an authorization to a general consent and two legal entities that were signed and dated and failed to indicate whether a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Client #3 was admitted on October 31, 2019 and was current at the time of the inspection. Client #3 had an authorization to a general consent that was signed and dated and failed to indicate whether a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Client #4 was admitted on October 14, 2019 and was current at the time of the inspection. Client #4 had an authorization to a funding source that was signed and dated and failed to indicate whether a copy of a client consent shall be offered to the client and a copy maintained in the client record.
Client #5 was admitted on November 20, 2019 and was discharged on December 2, 2019. Client #5 had an authorization to a legal entity that was signed and dated and failed to indicate whether a copy of a client consent shall be offered to the client and a copy maintained in the client record.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
Staff was retrained on February 3, 2020. Clinical supervisor will complete random chart audits weekly for the next 6 months, then bi-weekly for a year. The director will complete monthly chart audits.
refresher trainings will be held every 6 months to address turn around. |
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.
|
Observations
During a review of incident reports on January 7, 2019, the project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
There was an incident documented on August 31, 2019 that involved the presence of police personnel facility. No incident report was filed with the Department.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
Clinical Supervisor was retrained on 2/3/2020 on the process and need to fax to report to the DDAP. All Incident report fax receipts will be given to the director within 12 hours to ensure the process is completed. Effective immediately and ongoing. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
During a review of client records on January 7, 2020, the facility failed to include documentation of consent to treatment in the intake procedure in two out of seven client records.
Client # 1 was admitted on November 26, 2019 and was current at the time of the inspection. Client #1 checked off both "yes" and "no" on the consent to treatment form.
Client # 4 was admitted on November 20, 2019 and was current at the time of the inspection. Client #4 checked off both "yes" and "no" on the consent to treatment form.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Support staff retrained on 2/3/2020 in regards to weekend admissions and paperwork. All staff signed off on the training process and a new intake person was hired. All paperwork will be audited biweekly for 6 months then monthly by clinical supervisor, |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
During a review of client records on January 7, 2019, the facility failed to review, and update treatment and rehabilitation plans at least every 30 days in three out of seven client records.
Client #1 was admitted on November 26, 2019 and was current at the time of the inspection. There was a treatment and rehabilitation plan dated December 2, 2019. There should have been an update on or before January 2, 2020 but there was no update documented in the client record.
Client #3 was admitted on October 31, 2019 and was current at the time of the inspection. Client #3 had no treatment and rehabilitation plan, or a treatment and rehabilitation plan update documented in the client record.
Client #6 was admitted on January 2, 2019 and was discharged on March 21, 2019. There was a treatment and rehabilitation plan completed on January 6, 2019. The treatment and rehabilitation plan update was completed on February 14, 2019 which was eight days late. There should have been another treatment and rehabilitation plan update dated no later than March 14, 2019 but there was no update documented in the client record.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Facility staff was retrained on 2/3/2020 regarding the regulations on updating treatment and rehabilitation plans at least every 30 days. Clinical supervisor will audit charts weekly for 6 months and bi-weekly after that to ensure compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
During a review of client records on January 7, 2020, the project failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in six out of seven client records.
Client #1 was admitted on November 26, 2019 and was current at the time of the inspection. Client #1 was to have weekly individual counseling services per the treatment plan dated December 2, 2019. Client #1 had individual counseling services on December 2, 2019, December 9, 2019, December 16, 2019, December 23, 2019 and January 6, 2020. Client #1 did not have individual counseling services the week of December 30, 2019.
Client #2 was admitted on November 17, 2019 and was current at the time of the inspection. Client #2 was to have weekly individual counseling services per the treatment plans dated November 19, 2019 and December 19, 2019. Client #2 had counseling sessions on November 19, 2019, November 26, 2019 and December 19, 2019. There were no individual counseling services documented for the weeks of December 3, 2019, December 10, 2019, December 24, 2019 and December 31, 2019.
Client #3 was admitted on October 31, 2019 and was current at the time of the inspection. Client #3 had no documented treatment plans at the time of inspection. Client #3 had counseling services on November 1, 2019 and November 10, 2019.
Client #5 was admitted on October 14, 2019 and was discharged on December 2, 2019. Client #5 was to have weekly individual counseling services per the treatment plans dated October 18, 2019 and November 13, 2019. Client #5 had individual counseling services on October 18, 2019, October 25, 2019, November 1, 2019 and November 8, 2019. There were no individual counseling services documented for the weeks of November 15, 2019, November 22, 2019 and November 29, 2019.
Client #6 was admitted on January 2, 2019 and was discharged on March 21, 2019. Client #6 was to have weekly individual counseling services per the treatment plans dated January 6, 2019 and February 14, 2019. Client #6 had individual counseling services on January 2 2019, January 3, 2019, January 6, 2019 and January 13, 2019, January 20, 2019, January 27, 2019, February 3, 2019, February 10, 2019, February 17, 2019, February 24, 2019, March 3, 2019 and March 7, 2019. There were no individual counseling services documented for the weeks of March 14, 2019 and March 21, 2019.
These findings were reviewed with the project staff during the licensing process.
|
Plan of Correction
Clinical supervisor will audit charts weekly for 6 months and bi-weekly after that to ensure compliance with documentation of individual sessions documenting goal work from treatment plans.
Clinical team was retrained on 2/3/2020 regarding the regulations on documentation of individual sessions within 24 hours of completion of the session.
The director will randomly audit charts for the next 6 months to ensue clinical supervisor is following up with POC. |