INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8, 2022 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of six employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 3.
Employee # 3 was hired as a counselor on September 27, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 3's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee number six was demoted to a counselor assistant and given an annual training plan to ensure supervision under a full counselor to meet standard of clinical experience. the clinical supervisor will oversee process to ensure supervision in documented, and that going forward documentation is provided to support clinical experience |
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 policy and procedure and client records, the facility failed to document contacting the emergency contact after leaving the facility against medical advice in two of two applicable client records, # 5 and # 7.
Client # 5 was admitted on March 1, 2022 and was administratively discharged on July 22, 2022. There was no documentation of the emergency contact being contacted in the client record.
Client # 7 was admitted on September 27, 2022 and was administratively discharged on October 24, 2022. There was no documentation of the emergency contact being contacted in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff retrained on the record of service and the process of documenting the emergency contact. Staff signed attendance sheet and clinical supervisor will do weekly audits for the next 6 months then random audits going forward for compliance. |
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 one of one applicable client records reviewed, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project and the reason for termination.
Client # 5 was admitted on March 1, 2022 and was administratively discharged on July 22, 2022. There was no documentation of the client being notified, in writing, of a decision to involuntarily terminate the client ' s treatment at the project and the reason for termination.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical team was retrained on the discharge documentation requirement by director. The clinical supervisor will review all discharge paperwork prior to discharge to ensure compliance for the next 6 months. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on four of seven client records reviewed, the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project to include a record of service in client records # 1, # 3, #5, and # 6.
Client # 1 was admitted on September 28, 2022 and was still active at the time of the inspection. There were progress notes for counseling sessions on December 4, October 4, October 24, and October 5, 2022 that were not documented on the client record of service.
Client # 3 was admitted on October 26, 2022 and was still active at the time of the inspection. There were progress notes for counseling sessions on November 30, November 2, and October 26, 2022 that were not documented on the client record of service.
Client # 5 was admitted on March 1, 2022 and was discharged on July 22, 2022. There were progress notes for counseling sessions on July 25, 18, 11, 5, June 27, 20, 13, 6, 3, and 1, 2022 that were not documented on the client record of service.
Client # 6 was admitted on May 5, 2022 and was discharged on September 2, 2022. There were progress notes for counseling sessions on August 17, 24, 30, 2022 that were not documented on the client record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and clinical supervisor met with staff to redefine process of individual sessions which is document the record of service at the start of session and complete note at end of session. Counselors are responsible for the process daily and clinical supervisor will do weekly audits for the next 6 months, then random audits going forward. |
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 two of five applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur with treatment plan updates.
Client # 1 was admitted on September 28, 2022 and was still active at the time of the inspection. A treatment plan update occurred on October 28, 2022 and November 28, 2022. There was not a case consultation that occurred with the treatment plan updates.
Client # 6 was admitted on May 5, 2022 and was discharged September 2, 2022. A treatment plan update occurred on July 13, 2022 and August 13, 2022. There was not a case consultation that occurred with the treatment plan updates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will ensure that all case consultation notes are signed and placed in the client chart at the end of the consultation, as well as noting the record of service by each counselor in attendance. Director will do weekly audits for 6 months, then random audits going forward. |