INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica of SACA Drug and Alcohol Program 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 and a plan of correction is due on February 28, 2011.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to ensure that the project director meets the requirement for the position of project director.
The findings include:
The personnel records were reviewed on January 24, 2011 through January 25, 2011. Employee #1 was hired on 7/23/08 as the project/facility director. An interview was conducted with the project director/facility director revealed that he did not report to the board and was not responsible for the overall management of the project and staff and each drug and alcohol treatment facility within the project..
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Plan of Correction
Job description changed to require project director to report directly to the Board on 2/8/2011. Project director will be supervised by the board which will be responsible for annual review of the project director. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the policy and procedure manual, personnel files, and an interview with the facility director, the facility failed to document individual training plans timely or at all in two of three employee records.
The findings include:
On January 26, 2011, the policy and procedure manual and three personnel records were reviewed. Per the agency policy and procedure manual, each employee will have a completed individual training plan by July 30, of the new fiscal year. The facility's current training year runs from July 1, 2010 to June 30, 2011. The regulation requires individual training plans to be completed as a component of a staff development program, two employee records did not include documentation of a timely training plan for the current fiscal year.
Employee #1's training plan was due by July 30, 2010 and had not been completed until August 10, 2010.
Employee #3's training plan was due by July 30, 2010 and had not been completed until January 7, 2011.
The facility director was interviewed on January 26, 2011. The facility director confirmed that they were not completed per the facility's policy and procedure.
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Plan of Correction
Training plans for each employee will be completed by July 30 of each new fiscal year. Project director will be solely responsible for timely documentation of training plans. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection and an interview with the facility director, the facility failed to ensure that the facility's hot water temperature does not exceed 120F.
The findings include:
The physical plant inspection took place on January 26, 2011, beginnig at approximately 3:42 pm. During the inspection of the restrooms, the employee restroom showed that the water temperatures exceeded the required 120F. The employee restroom hot water temperature read 153F, the male restroom hot water temperature read 150F and female restroom hot water temperature read 144F. An interview with the facility director on January 26, 2011 confirmed that those temperatures exceeded the required 120F water temperature.
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Plan of Correction
Project director discussed water temperatures with facility maintence supervisor who adjusted them on 1/31/2011 and rechecked on 2/22/2011. Hot water temperature at 106F in restrooms.
Project director asked that a thermostat security device be purchased and installed. Facility maintenance supervisor purchased security device and showed it to project director on March 15, 2011. Project director and facility maintenance supervisor to recheck water temperatures in all three facility bathrooms to ensure that temperatures are in compliance and then the thermostat security device will be installed on March 16, 2011. Maintence supervisor will check on temperatures on a monthly basis and report to facility director. Only they will have keys to thermostat security device. Project director is responsible for compliance and will document temperatures monthly. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection and an interview with the facility director, the facility failed to ensure that the facility did not permit heaters that are not mounted in the facility..
The findings include:
The physical plant inspection took place on January 26, 2011 at around 3:42 pm. During the inspection it was observed that there were two space heaters that were not mounted located under the hallway sink of the facility. An interview with the facility director on January 26, 2011 confirmed that there were two space heaters that were not mounted located under the sink in the hallway of the facility.
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Plan of Correction
The two space heaters that were not mounted were removed from the facility on 1/27/2011. On 3/15,2011 the facility director wrote and passed to each facility staff member a document stating that "According to state regulations, heaters that are not permanently mounted or installed are not permitted in this facility. Failure to follow this regulation will result in disciplinary action,possibly termination." Each staff member signed the document which will be place in their personnel files and the director searched each office. No such heaters were found. The facility director will conduct periodic office searches.The facility director will be responsible for this action to be implemented. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on the physical plant inspection and an interview with the facility director, the facility failed to ensure that all stairways, hallways and exits were unobstructed.
The findings include:
The physical plant inspection took place on January 26, 2011, beginning at approximately 3:42 pm. During the inspection it was observed that the exit from the back hallway leading to an alley had two exits on either side which were both gated and locked. During an interview with the facility director on January 26, 2011, the licensing inspector was informed that "we do not use it as an exit", however, the door had a lit "Exit" sign directly above it, clearly indicating the door was an exit.
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Plan of Correction
On 3/1/2011 gate nearest back hallway exit was unlocked permitting passage from the facility. Projector will check exit on a monthly basis. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to have documentation through written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage.
The findings include:
The facility's policy and procedure manual was reviewed on January 26, 2011. The facility is required to make provisions to ensure that they maintain a written letter of agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage. At the time of the inspection, the policy and procedure manual was reviewed and there was no documentation of a written letter of agreement in place. An interview with the facility director on January 26, 2011 confirmed that the facility did not have a written letter of agreement with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.
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Plan of Correction
Nuestra Clinica and Lancaster Regional Hospital (LRH) reached a verbal reciprocal agreement on 3/17/2011 for Lancaster Regional Hospital to provide 24-hour emergency psychiatric and medical coverage and Nuestra Clinica to provide outpatient mental health and substance abuse treatment. Written letter of agreement sent to Lancaster Regional Hospital on 3/17/2011 and is expected to be returned by 3/18/2011. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and an interview with the Facility Director, the facility failed to include documentation of the client's family medical history in nine of eleven records reviewed.
The findings include:
Eleven client records were reviewed on January 26, 2011. Medical histories were required in nine of the eleven client records, #1, 2, 3, 4, 6, 7, 8, 9 and 10. Medical histories must include documentation of the client's family medical history. Client records #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 did not have the client's family medical history documented in records reviewed. An interview was conducted with the facility director on January 26, 2011 and he confirmed that the client's family medical histories was not documented in client records #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
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Plan of Correction
New documentation forms were implemented on 2/3/2011 that contain documentation of family history. Clinical supervisor addressed staff on 2/11/2011 on utilization and integration of new documentation. Project director will ensure that forms are used by reviewing records of supervision and chart reviews weekly. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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 and an interview with the facility director, the facility failed to document psychosocial evaluations in eight of eleven client records.
The finding includes:
Eleven client records were reviewed on January 26, 2011. Psychosocial evaluations were to be documented in eight client records, #1, 2, 3, 4, 6, 7, 10 and 11. An interview with the facility director took place on January 26, 2011 and he confirmed that it was not documented.
Client records #1, 2, 3 and 10 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client records # 4, 6, 7 and 11 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
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Plan of Correction
Clinical supervisor reviewed results of state inspection and advised staff on 1/30/2011 including psychosocial evaluations and clinical impressions.
Clinical supervisor will conduct an additional training on Documentation in the Substance Abuse Field on March 18,2011. Staff will receive certificate of proof of training which will be placed in staff personnel file.
Clinical supervisor will continue to review staff documentation in chart reviews on a weekly basis as well as in supervision, both will be documented. Project director will be responsible to verify improvement through records of supervision and chart reviews on a weekly basis. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 client records and an interview with the facility director, the facility failed to document type and frequency in eight of eleven client records reviewed.
The findings include:
Eleven client records were reviewed on January 26, 2011. Type and frequency was required to be documented on the clients comprehensive treatment plan in client records, #1, 2, 3, 4, 6, 7, 10 and 11. An interview with the facility director confirmed that they type and frequency was not documented on the client's comprehensive treatment plan in client records, #1, 2, 3, 4, 6, 7, 10 and 11.
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Plan of Correction
Clinical supervisor reviewed results of state inspection with staff on 1/30/2011 including written documentation of type and frequency of treatment.
Clinical supervisor will conduct an additional training on Documentation in the Substance Abuse Field on March 18,2011. Staff will receive certificate of proof of training which will be placed in staff personnel file.
Clinical supervisor reviews charts and holds weekly supervision and will ensure that documentation of type and frequency of treatment occurs. Project director will review records of supervision and chart reviews to verify improvement. |
709.93(a)(8) LICENSURE Client records
709.93. 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 the review of client records and an interview with the facility director, the facility failed to document case consultations within the ninety day time frame in two of eleven client records reviewed.
The findings include:
Eleven client records were reviewed on January 26, 2011. Per agency policy, case consultations shall be completed quarterly. Case consultations were required in two client records, specifically client records #4 and 5. The facility did not document a case consultation within the ninety day time frame in client records # 4 and 5. An interview with the facility director on January 26, 2011 confirmed that the client's case consultations were not documented in client records #4 and 5.
Client # 4 was admitted on October 5, 2010. The case consultation was due by January 5, 2011. As of the date of inspection, there had not been a case consultation completed for client #4.
Client # 5 was admitted on March 15, 2010 and discharged on August 3, 2010. The case consultation was due by June 15, 2010. As of the date of inspection, there had not been a case consultation completed for client #5.
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Plan of Correction
Clinical supervisor reviewed results of state inspection with staff on 1/30/2011 including the requirement of case consultations within the ninety day time frame.
Clinical supervisor will conduct an additional training on Documentation in the Substance Abuse Field on March 18,2011. Staff will receive certificate of proof of training which will be placed in staff personnel file.
Clinical supervisor will ensure this ocurs through weekly supervision and chart reviews. Project director will verify that case consults are completed in required time frame through records of supervision and chart reviews. |
709.93(a)(10) LICENSURE Client records
709.93. 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 and an interview with the facility director, the facility failed to document discharge summaries in five of five discharge records reviewed.
The findings include:
Eleven client records were reviewed on January 26, 2011. Discharge summaries where required in five discharge records reviewed, #5, 6, 7, 8 and 11. Discharge summaries are to have documentation of the client's reason for treatment, services offered, response to treatment and the client's status at the time of discharge. Client records #5, 6, 7 and 8 did not have documentation of client's reason for treatment and the client's response to treatment. An interview with the facility director on January 26, 2011 confirmed that the client's reason for treatment and the client's response to treatment was not documented in client records #5, 6, 7 and 8.
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Plan of Correction
Clinical supervisor reviewed results of state inspection with staff on 1/30/2011 including more thorough discharge summaries with client's reason for treatment and client response to treatment.
Clinical supervisor will conduct an additional training on Documentation in the Substance Abuse Field on March 18,2011. Staff will receive certificate of proof of training which will be placed in staff personnel file.
Clinical supervisor will continue instruction and review through weekly supervision and chart reviews. Project director will verify that discharge summaries are thoroughly completed through records of supervision and chart reviews. |
709.93(a)(11) LICENSURE Client records
709.93. 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 and an interview with the facility director, the facility failed to document follow-up information in three of five discharge records reviewed.
The findings include:
Eleven client records reviewed on January 26, 2011. Follow-up information were required in three of the five discharge records, #5, 6 and 8. Per the facility's policy and procedure, all clients will either be contacted within 7 days if being referred or 30 days following their discharge date. An interview was conducted with the facility director on January 26, 2011 and it was confirmed that follow-up contact was not documented in client records #5 and 8. Also, the follow-up information for client record #6 was documented late.
Client #5 was admitted on March 26, 2010 and discharged on August 3, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. The follow-up should have taken place by September 3, 2010.
Client #6 was admitted on May 26, 2010 and discharged on July 6, 2010. The follow-up took place on August 9, 2010. The follow-up should have been documented by August 6, 2010.
Client #8 was admitted on July 16, 2010 and discharged on September 14, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. Their follow-up should have taken place by October 14, 2010.
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Plan of Correction
Clinical supervisor reviewed results of state inspection with staff on 1/30/2011 including discharge summaries and timely follow-ups.
Clinical supervisor will conduct an additional training on Documentation in the Substance Abuse Field on March 18, 2011. Staff will receive certificate of proof of training which will be placed in staff personnel file.
Clinical supervisor will ensure that timely follow-ups are taking place through weekly supervision and chart review. Project director will be responsible to verify follow-up contact within required time frame through records of supervision and chart reviews |