INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in the bathrooms on each floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/24/2025, this facility is temporarily not operating. Until a mechanical dryer is purchased for each bathroom, Residential Aides will be required to ensure that all bathrooms are checked for paper towels during every daily shift. This responsibility will be added to their job descriptions.
A supply log checklist will be implemented so that Residential Aides on each shift can verify that all bathrooms have been checked during every shift change. Residential Aide immediate Supervisor (Facility Manager) will be responsible for ensuring corrective action is implemented.
Noncompliance may result in disciplinary action, up to and including termination if necessary. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. The front and side doors on the first floor require a key fab to open.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
As of December 24, 2025, this facility is temporarily not in operation. However, all stairways, hallways, and exits from individual rooms and from the residential facility are fully unobstructed. When the facility reopens, key fobs will be required for entry only and will not be needed to exit the facility. SUD Director and SACA Development maintenance staff will ensure that this corrective action is implemented. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher in the staff office was not inspected in the last year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/24/2025, this facility is temporarily not in operation, no staff on site (date of reopening is not yet determined). By the time the facility reopens, the previously uninspected fire extinguisher will have been inspected. Upon review of the fire safety service receipt provided by CINTAS, it was determined that this extinguisher was missed during the last inspection in Oct 2025. SACA CEO has communicated with the SACA Development Maintenance team to ensure the inspection of the missed extinguisher is scheduled on or before 02/01/2025. Once the facility is operational, a comprehensive log of all fire extinguishers and their locations will be maintained by the newly appointed SUD Director to ensure that no extinguishers are overlooked in the future. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of inpatient client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #6 was admitted on July 28, 2025 and discharged on August 15, 2025.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 12/24/2025, this facility is temporarily not operating. Upon reopening, any involuntary discharge will include written notification to the client of any decision to involuntarily terminate the client's treatment at the project. This procedure will be implemented when the facility reopens and will be incorporated into the project's Provider Policy and Procedure Manual. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the inpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in eight out of eight client records reviewed.
Client #1 was admitted on November 6, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 9, 2025 with no type or frequency identified.
Client #2 was admitted on November 10, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 15, 2025 with no type or frequency identified.
Client #3 was admitted on November 10, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 14, 2025 with no type or frequency identified.
Client #4 was admitted on November 12, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 16, 2025 with no type or frequency identified.
Client #5 was admitted on July 9, 2025 and discharged on August 20, 2025. A comprehensive treatment plan was developed on July 16, 2025 with no type or frequency identified.
Client #6 was admitted on July 28, 2025 and discharged on August 15, 2025. A comprehensive treatment plan was developed on August 4, 2025 with no type or frequency identified.
Client #7 was admitted on September 3, 2025 and discharged on October 15, 2025. A comprehensive treatment plan was developed on September 10, 2025 with no type or frequency identified.
Client #8 was admitted on September 25, 2025 and discharged on November 6, 2025. A comprehensive treatment plan was developed on October 1, 2025 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/24/2025, this facility is temporarily not operational. Upon reopening, the newly appointed SUD Director will be responsible for auditing client records within one week of admission to ensure that treatment plans clearly identify the type and frequency of services provided. The Director will also hold staff accountable for any noncompliance. The Director of Quality, Control & Compliance will conduct random bimonthly audits to verify ongoing compliance with this requirement. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of inpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in eight out of eight applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed weekly following admission.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 12/24/2025, this facility is temporarily not operating. Upon reopening, a weekly log of case consultations will be required in accordance with policy and must be maintained by the newly appointed SUD Director to ensure that the cases are being reviewed. The Policy and Procedure Manual has been updated on 01/14/2026 to reflect this requirement. Disciplinary action will be taken if responsible staff fail to comply. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of inpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in four out of four applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed seven and 15 days following discharge.
Client #5 was admitted on July 9, 2025 and discharged on August 20, 2025.
Client #6 was admitted on July 28, 2025 and discharged on August 15, 2025.
Client #7 was admitted on September 3, 2025 and discharged on October 15, 2025.
Client #8 was admitted on September 25, 2025 and discharged on November 6, 2025
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 9, 2024 licensing inspection.
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Plan of Correction
As of 12/24/2025, this facility is temporarily not operating. When the facility reopens, The appointed SUD Director will review all policies and procedures with new staff. Flags will be placed in the client's EMR upon discharge by the Counselors and may only be marked as resolved by the SUD Director after the Counselor or Case Manager provide documented evidence that follow-up has occurred. These flags will include due dates and serve as alerts to ensure staff complete required follow-up actions accurately and on time. |