INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4 through December 5, 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(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for clinical supervisors in one of one personnel record.
The findings include:
Seven personnel records were reviewed on December 4, 2012. Employee # 3 was the clinical supervisor for the July 1, 2011 to June 30, 2012 training year. Employee # 3 was required to complete 12 clock hours of annual training. Employee # 3 failed to document 12 clock hours of annual training. There were only six hours of annual training documented for this employee for the 2011/2012 training year.
This finding was confirmed by the Associate Director and was not disputed.
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Plan of Correction
A new clinical supervisor with the appropriate training hours was appointed as of December 1,2012. In the future the program director will oversee the scheduling of trainin hours for the clinical supervisor and the program director will audit the personell file quarterly to assure compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of employee personnel records and training documentation, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel record reviewed.
The findings included:
Seven personnel records were reviewed on December 4, 2012. One personnel record was a counselor and was required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired on April 7, 2007 and promoted to counselor on October 25, 2008. The facility training year is from July 1, 2011 to June 30, 2012. Employee # 7 only completed 17 clock hours of annual training for the 2011/2012 training year.
The Associate Director confirmed this finding and was not disputed.
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Plan of Correction
The clinical supervisor will oversee the scheduling of training hours for all counselors. The clinical supervisor will be responsible for compliance with the training plan and will do so through quarterly reports to the program director. |
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 a physical plant inspection, the residential 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 December 5, 2012. During the inspection, a two foot square area of the sub floor in front of the shower in the handicapped bathroom located on the first floor had a chipped tile and was soft underfoot. This was a potential hazard.
Additionally, there was a chipped tile in the bathroom attached to Room "F". The tile was located in front of the vanity and was a tripping hazard.
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Plan of Correction
The associate director had the maintenance staff make the repairs to both bathrooms. The floor tiles were rmoved and new flooring installed which included replacement of the floor tiles.In the future weekly maintainence checks will be completed by the house manager supervisor and defects will be reported to program director along with requisition for repairs. |
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 a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the purpose of disclosure in four of four client records.
The findings included:
Five client records were reviewed on December 5, 2012. Four client records were reviewed for an informed and voluntary consent from the client that included the purpose of disclosure. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record, including the purpose of the disclosure.
Four of the four client records reviewed included a consent to release information for a government agency that failed to document the purpose of the consent to release.
This was noted in client records # 2, 3, 4, and 5.
The associate director confirmed that the release of information forms failed to document a purpose.
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Plan of Correction
The associate director met with and retrained the intake person regarding the completion of the consent forms. In addition, the intake staff will attend and addtional confidentiality training. to ensure compliance the associate director will audit the charts weekly along with inhouse trainings. |
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 a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one client records.
The findings include:
Five client records were reviewed on December 5, 2012. Of these records, two records were discharged client records. One record required written notification to the client informing him of the decision to terminate the client's treatment. The facility failed to document notification to the client in client record # 1.
This finding was confirmed by the Associate Director.
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Plan of Correction
The associate director met with all stff on december 11,2012 and discussed the need for all forms to be completed i the discharge section. the clinical supervisor will complete random audits to ensure compliance. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment in one of one record reviewed.
The findings include:
Five client records were reviewed on December 5, 2012. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record # 1.
This finding was confirmed by the Associate Director and was not disputed.
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Plan of Correction
The clinical supervisor will be responsible for randome audits of charts. These audits will be done monthly. the clincial staff met with the associate director and clinical supervisor on December 11, 2012 to advise them on the correct documetnation procedures. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document the lengths and patterns related to the client's progression of drug and alcohol use in four of four records reviewed.
The findings were:
Five client records were reviewed on December 5, 2012. Four records were reviewed for documentation of drug and alcohol history that included lengths and patterns related to the client's progression of use. The facility failed to document the lengths and patterns related to the client's progression of use in client records # 2, 3, 4, and 5.
This finding was discussed with the associate director and was not disputed.
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Plan of Correction
The clinical supervisor met with the counselors on December 11, 2012 regarding the in depth information needed for documenting patterns of use. The clinical supervisor will do weekly audits of the charts to ensure compliance. |