INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17-18, 2012 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records and the staffing requirements facility summary report, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
On January 17-18, 2012, nine personnel records requiring documentation of the mandatory training's were reviewed, were reviewed. There was no documentation of HIV/AIDS or TB/STD training in two of nine employee records reviewed, #8 & 9.
Employee #8 was hired January 31, 2009 and was required to have HIV/AIDS & TB/STD training by January 31, 2011. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of January 18, 2012.
Employee #9 was hired July 21, 2009 and was required to have HIV/AIDS & TB/STD training by July 21, 2011. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of January 18, 2012.
An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
Employee's #8 & #9, have been scheduled for HIV training through BDAp in Phialdelphia on March 15, 2012.
In additon the associate director will schedule bi-yearly trainings to assure that new hires complete this training within the stated guidelines. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities staff schedule from December 19, 2011 through January 18, 2012, the facility failed to provide a sufficient number of staff persons trained in Cardio Pulmonary Resuscitation (CPR) and First Aid (FA) during the project's hours of operation.
The findings include:
On January 17-18, 2012 copies of staff CPR and First Aid cards and the December and January work schedule as provided by the facility were reviewed.
Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR coverage during several shifts of the project's hours of operation. The facility works remains open on a continual basis.
From 7 PM to 11:30 PM Monday through Thursday no CPR coverage.
From 4 PM to 11:30 PM Friday no CPR coverage.
From 11:30 PM to 7 AM Monday through Friday no CPR Coverage
From 7 AM to 8 AM and 4 PM to 7 AM Saturday to Saturday no CPR Coverage
From 7 AM to 7 AM on Sunday to Monday no CPR Coverage
No coverage for on call van driver
In addition, the facility failed to provide CPR coverage from 3 PM to 11:30 PM on January 2, 2012.
An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings. The facility was fully aware of the lack of coverage due to a schedule change with the training agency. The facility had made an efficient effort to correct the issue by conducting training on January 19, 2012 to staff to cover the areas that were lacking coverage. The facility will also be holding training for all staff on January 24, 2012.
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Plan of Correction
The first 8 identified personel completed CPR training on 1/19/12 and docuemtnation was sent to the licensing board to confirm training was completed. All other staff completed training on January 24th at the local Red Cross and all staff are currently certified in both CPR and First Aide at this time.
To ensure compliance in this field the we have an inhouse trainer assisgned to this facility and the trainings are scheduled 6 months prior to the date of expiration. It is the respnsibiltiy of the nurse and the associated director to ensure compliance. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation during a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on January 18, 2012 at approximately 1:30 PM.
It was observed during the physical plant inspection that the heating system room was used for storage.
The furnace was uncovered and fire flames were observed coming out of the bottom of the furnace.
In addition, there was clutter around the uncovered furnace such as chairs, bed frames, a ball, piled up boxes, tables, and computers.
The assistance director confirmed the findings.
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Plan of Correction
The heating room was cleaned out on 2/19/12 and all storage was moved to another location off premises. A picture was sent to DOH to verify the room was cleaned out.
**Staorage facility has been obtaind to make sure that we have adequate outside storage. This is the immediate responsbility of the house manager supervisor. This will be checked monthly by teh associate director. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment.
The findings were:
On January 17-18, 2012, nine personnel records requiring documentation that staff were instructed in the use of fire extinguishers upon staff employment were reviewed.
Employee #3 was hired on April 7, 1997; however as of the date of the inspection Employee #3 did not have the required training on the use a fire extinguisher .
An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
On January 24, 2012 employee # 3 was given the fire extinguisher training and the was able to pass the written test. Certificate placed in the file as a record of completion.
Quartelry Fire Safety and training will be held and it will be the responsibility of the associate director to ensure compliance. |
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, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings were:
On January 17-18, 2012, nine personnel records requiring documentation that all personnel on all shifts were trained to perform assigned tasks during emergencies.
Employee #3 was hired on April 7, 1997 and was required to have training documented at that time; however, at the time of the inspection on January 18, 2012, there was no documentation that employee #3 had completed the training.
An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
On January 24, 2012 emplyee #3 completed an in house trainig on emergency and disaster procedures. Documentation was placed in the file.
Steps have been included in the hiring process that requires all new hires to complete the training prior to working their first shift. This will be the responsiblity of the associate director. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the project's annual report, the facility's web page and an interview with the Project Director and Assistant Director, the facility failed to make available to the public the 2010-2011 annual report by the end of the facility's fiscal year.
The findings include:
The facility's annual report and web were reviewed on January 19, 2012.
The Project Director and Assistant Director stated that the board of directors uploaded the annual report to the web site on January 18, 2012. However, the annual report available on line was the annual report for the 2009-2010 fiscal year not the 2010-2011 fiscal year.
The Project Director and Assistant Director confirmed that the 2010-2011 annual report was not made available to the public by the end of the fiscal year.
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Plan of Correction
The annual report is now posted on the SACA website as of Janaury 19,2012 and the governing body has agreed to make this report avaialbe by the end of the fiscal year beginning with June 30th 2012 and going forward. . The respnsibility for compliance in this issue is the CEO. |
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 the review of client records, the facility failed to ensure that the client was notified of his/her right to revoke client consents to release information verbally or in writing.
The findings include:
On January 18, 2012, eight client records requiring documentation of informed and voluntary consents were reviewed . The right to revoke the consent was not documented on the informed and voluntary consent forms in client records, #1, 2, 3, 4, 5, 6, 7 and 8.
Also, the facility exceeded 4 PA Code. 255.5 by exceeding what it to be sent out to a government agency. Per the State Law government agencies are restricted to: 1) Nature of the project, 2) Whether or not the client it in treatment, 3) The client's prognosis, 4) A brief description of the client's progress and 5) a short statement as to whether the client relapsed and the frequency of such relapse.
On May 24, 2011 the facility sent to a government agency the following information: the client's picture ID, client's social security number, the client's insurance card and a letter with identifying information of the client.
An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
Consent forms informed the client that they had the right to revoke consent in writing. these forms were corrected to inform the client that hey had the right to revoke, rather than specifying whether it had to be written or verbal.
In addition the staff was retrained on 01/23/12 regarding what information is allowed to be given to oustside entities. Staff will also attend confidentiality trainings when available through BDAP to reorient them to the law and any updates that have taken place. The associate director will shedule and oversee compliance in this area. |
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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the purpose of disclosure in five of eight client records reviewed.
The findings include:
On January 18, 2012, eight client records requiring documentation of the purpose for release of information were reviewed. The purpose of disclosure was not documented in the informed and voluntary consent forms in client records, #3, 5, 6, 7 and 8. An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
The staff was retrained on 1/23/12 of the state law requirements and the importance of docuemnting what purpse the shared information can be used in with oustside entities. Staff will also attend confidentiality trainings provided by BDAP yearly to re-orient them with the law and any updates that have taken place
this will be overseen by the associate director under the direction of the program director.
Additionally, chart audits will be done randlomly to verify compliance. |
709.28(c)(5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the date signature of witness in five of eight client records reviewed.
The findings include:
On January 18, 2012, eight client records were reviewed to ensure that the consent to release information fomrs incluuded a dateed signature.
The dated signature of witnesses was documented on different date of the signature of the client in the informed and voluntary consent forms in client records, #1, 4, 5 and 8. An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
Client record #1 had a consent to release form dated by the client on January 5, 2012 and the witness signed and dated January 4, 2012, a day before the client signed and dated the consent to release form.
Client record #4 had a consent to release form dated by the client on November 9, 2011. The witness signed and dated the consent form on November 10, 2011, a day after the client signed and dated the consent to release.
Client record #5 had a consent to release form dated by the client on July 27, 2011. The witness signed and dated the consent form on July 15, 2011, twelve days before the client signed and dated the consent to release.
Client record #8 had a consent to release form dated by the client on October 11, 2011. The witness signed and dated the consent form on September 30, 2011, eleven days before the client signed and dated the consent to release.
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Plan of Correction
The administrative assistant was retrained on the procedure and purpose of the consent form on 1/24/12. The assistant director explained that consent forms can not be completed unless client is present and they must be signed at the date and time of the meeting. All staff will attend BDAP confidentiality trainings yearly to reorient them to the law and any updates that have taken place.
Random chart audits will be done by the associate director to ensure compliance.
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709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on the review of the facilities medication administration records for six clients, the facility failed to maintain accurate records on the individual medications.
The findings include:
Six medication administration records were reviewed on January 18, 2012. Six of those listed inventory records that were inconsistent. An interview with the Assistant Facility Director on January 18, 2012 confirmed the findings.
Client medication record #1
Drug: Fluconazole 100 mg
Prescribed on 1/9/12
Frequency: 1 tablet by mouth once daily
Dates not taken: Took twice on 1/15/12 and did not take any on 1/16/12
Client medication record #2
Drug: Klor-Con-M 10 mg
Prescribed on 12/29/11
Frequency: 1 tab once a day
Dates not taken: 1/2/12
Drug: Noltrexone 50 mg
Prescribed on 10/29/11
Frequency: 1 one tablet by mouth once daily
Dates not taken: 1/2/12
Drug: HCTZ 25mg
Prescribed on 10/24/11
Frequency: 1 tablet by mouth once daily
Dates not taken: 1/2/12
Drug: Klor-Con
Prescribed on 10/24/11
Frequency: 1 tablet by mouth once daily
Dates not taken: 1/2/12
Drug: Celaxa 40 mg
Prescribed on 10/24/11
Frequency: 1 tablet once daily
Dates not taken: 1/2/12
Drug: Diphenhydramine 50 mg
Prescribed on 11/22/11
Frequency: Take 1 capsule by mouth at bedtime
Dates not taken: Not taken on 12/3, taken twice on 12/4, not taken on 12/15 and not taken on 12/9-11/11.
Client medication record #3
Drug: Nicotine patch 21mg
Prescribed on 12/12/11
Frequency: Place 1 patch daily remove prior patch
Dates not taken: Did not take on 12/22, 12/24, 12/26-28, 12/30-31, 1/1-2 and 1/16.
Drug: Omeprazole 40 mg
Prescribed on 10/27/11
Frequency: Take 1 capsule daily in morning
Dates not taken: Did not take on 12/19, 12/22, 12/27, 1/2 and 1/9.
Drug: Lisinopril 20 mg
Prescribed on 10/27/11
Frequency: 1 tablet by mouth daily
Dates not taken: Not taken on 12/20, 12/22, 12/24-25, 12/27-28, 12/31, 1/2 and 1/18.
Drug: Not documented
Prescribed on 12/21/11
Frequency: 70 units in Am and 30 units in Pm
Dates not taken: Taken once on 12/22, not taken on 12/24, 12/26, only taken once 12/27, only taken once 12/29, only taken once on 1/11 and not taken on 12/16.
Client medication record #4
Drug: Gabapentin 600 mg
Prescribed on 11/24/11
Frequency: 1 tab x 3 daily by mouth
Dates not taken: only taken twice on 1/17
Drug: Citalopram 20 mg
Prescribed on: 11/24/12
Frequency: 1 tab PO at bedtime
Dates not taken: taken twice on 1/13, not taken on 1/14 and not taken on 1/17
Drug: Olanzapine 10 mg
Prescribed on: 11/24/11
Frequency: 1 tab at bedtime
Dates not taken: not taken on 1/17
Drug: Benztropine Mesylate
Prescribed on: Not documented
Frequency: 1 tab every 12 hours
Dates not taken: Not taken a prescribed for the month of December 2011 and January 2012. Not taken it every 12 hours.
Drug: Folic Acid 1 mg
Prescribed on: 11/24/11
Frequency: 1 tablet by mouth daily
Dates not taken: Taken twice on 1/17/12
Drug: Vitamin B-12
Prescribed on: 11/24/11
Frequency: 1 tab PO every day
Dates not taken: Taken twice on 1/17/12
Client medication record #5
Drug: Lisinopril 10 mg
Prescribed on: 12/15/11
Frequency: 1 tab once a day
Dates not taken: Not taken on 12/27/11
Drug: Omeprazole 40 mg
Prescribed on: 12/15/11
Frequency: 1 tab once a day
Dates not taken: Not taken on 12/27/11
Client medication record #6
Drug: Meprazole 20 mg
Prescribed on: 11/15/11
Frequency: Take 1 capsule by mouth once daily
Dates not taken: Took twice on 12/25/11
Drug: Corgard 20 mg
Prescribed on: 11/15/11
Frequency: Take 1 tablet by mouth once daily
Dates not taken: Not taken on 12/23, not taken on 12/27-30 and not taken on 1/17
Drug: Celexa 40
Prescribed on: 11/29/11
Frequency: Take 1 tablet by mouth at bedtime
Dates not taken: Not taken on 12/16/11
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Plan of Correction
The nurse has completed and additional med-education training with the staff that had inconsistencies in docuementation. Additionally, the medicaton book has been updated and the forms were made eaiser to understand and the process of documentation will be monitored by the nurse and the medical director. If a client refuses medication the primary counselor will be notified and steps will be taken to address the concerns. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations in eight of eight client records.
The findings include:
On January 18, 2012 eight client records requiring of physical examination were reviewed. The facility failed to document on the physical examinations the client's general appearance and the physicians impressions of the client. An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
Complete History and Physicals were documented by the medical director and in all 8 charts. The reviewers determined that the general appearence section did not give a complete impression of the client's physcial well being. The medical director was informed of the state requirement and the medical director assumed responsibility of completing a better picture of the general appearence section of the History & Physical at time of exam.A section was addedc to the History Physcal to allow for completion of the description. In addition the History & Physical will be typed for improved clarity. The nurse will monitor the doctors notes to ensure compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and/or impressions of the client in eight of eight client records.
The findings include:
Eight client records were reviewed on January 18, 2012. A psychosocial evaluation was required in eight of those records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with Project Director and Assistant Director on January 18, 2012 confirmed the findings.
Psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
Psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's support systems and how they would relate to treatment.
Psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
Psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's negative factors and how they would impact treatment.
Psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the counselors conclusions/impressions of the client.
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Plan of Correction
Teh progam director,associate director and clinical supervisor met with the clinical staff and explained that the psychsocials, although completed, were not in depth enough to portray a complete composite picture of the clients. The clinical staff was also given examples of an appropriate narrative, clinical evaluation, strenths/assessts, barriers/negative factors, support systems, coping mechanisms to use as ga guide for future treatment planning. The staff will attend ongoing treament planning trrainings to increase skills in this area and the charts will be audited by the clinical supervisor at random times and dates. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document discharge summaries in four of four discharge records reviewed.
The findings include:
On January 18, 2012, four discharged client records requiring discharge summaries were reviewed. were reviewed. Four out of four records reviewed, #5, 6, 7 and 8 did not have the reason for treatment documented in the discharge summary.
An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
The clinical director, program director, and assocaite director explained what was required for the appropriate docuemtation of the reason for treatment. Program director and clinical supervisor will complete random chart audits to ensure compliance with this process. In addition on going trainings will be provided through BDAP and inhouse supervisors. |
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 client records, the facility failed to document a follow up attempt in two of four discharge client records.
The findings include:
Per the facility's policy and procedure follow-up attempts will take place 7 days if being referred and 30 days all others.
On January 18, 2012, four discharged client records requiring documentation a follow-up were reviewed. The facility did not document a follow up in two of four client records reviewed , #5 and 6.
Client #5 was admitted on May 16, 2011 and discharged on August 1, 2011. A follow up attempt was due by August 8, 2011 due to the client being referred to a recovery house. The follow-up attempt took place on July 29, 2011 a day before the client was release from the program.
Client #6 was admitted on April 4, 2011 and discharged on July 22, 2011. A follow-up attempt was due by July 29, 2011 due to the client being referred to a recovery house. The follow-up attempt was not documented in record #6.
An interview with the Project Director and Assistant Director on January 18, 2012 confirmed the findings.
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Plan of Correction
The associate director retrained the administrative staff on the process of completing the follow up forms and the importance of documenting informaion in a clear, concise and correct manner. Copies of the follow up forms, both 7 & 30 day, must be given to the associate director on a weekly basis for review. |