INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 26, 2011 licensure renewal inspection. The follow-up inspection was conducted on June 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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.
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Plan of Correction
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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
As of today's date 6/29/11 all training plans have been completed for the facility's upcoming training year, which runs from July 1, 2011 to June 30, 2012. The facility director is solely responsible for their completion. |
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 document provided by the facility on June 14, 2011 did not include documentation that the hospital provided 24 hour emergency psychiatric and medical coverage.
An interview with the facility director on June 14, 2011 confirmed that the facility did not have documentation on the agreement stating that the hospital provided 24 hour emergency psychiatric and medical coverage.
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Plan of Correction
The facility contacted the licensed hospital to amend the written referral agreement to include a clause that states that they are available for 24 hour emergency psychiatric and medical coverage and they agreed. Amended referral was sent out 6/24/11 and is expected to be returned shortly.
On June 29, 2011 facility received amended referral agreement containing 24 hour emergency psychiatric and medical coverage.
As of July 7, 2011 facility director will review all referral agreements on an annual basis and update as needed. |
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 four of eight client records.
The finding includes:
Eight client records were reviewed on June 14, 2011. Psychosocial evaluations were to be documented in four client records, #1, 2, 3 and 4.
Client records #1 failed to include documentation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's conclusions/impressions.
Client records #2, 3 and 4 failed to include documentation of the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
This is a repeat citation.
The facility was previously cited for noncompliance with this standard during the January 26, 2011 licensing inspection. The facility's plan of correction submitted on March 10, 2011 and approved on March 17, 2011 stated the following:
"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."
An interview with the facility director took place on June 14, 2011 and he confirmed that it was not documented.
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Plan of Correction
Training did take place on March 18,2011 and was documented in the staff member's personnel chart but was not placed in the proper training section. It is in the proper section now.
Clinical supervisor will focus the next 4 supervisory sessions, from July 1 - July 22, 2011 on fine-tuning client records. This will be documented in supervisory session records. Project director will initial this documentation after reviewing the charts worked on.
After this period, charts will be closely monitored by at weekly supervision by clinical supervisor who
will report any defiencies to facility director.
As of August 1,2011 clinical supervisor will provide training on a quarterly basis with documentation provided as well as suggest outside traings that supervisor feels will prove beneficial.
Facility director is responsible that the above takes place. |
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 quarterly time frame in three of five client records reviewed.
The findings include:
Case consultations were required in five client records, specifically client records #1, 3, 4, 5 and 6. The facility did not document a case consultation within the quarterly time frame in client records # 1, 5 and 6.
Client # 1 was admitted on January 28, 2011. The case consultation was due by April 28, 2011. The case consultation was not completed until June 6, 2011.
Client # 5 was admitted on December 29, 2010 and discharged on April 11, 2011. The case consultation was due by March 29, 2011. As of June 14, 2011 there was no documentation of a case consultation for client #5.
Client # 6 was admitted on December 17, 2010 and discharged on June 1, 2011. The case consultation was due by March 17, 2010. As of June 14, 2011 there was no documentation of a case consultation for client #6.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the January 26, 2011 licensing inspection. The facility's plan of correction submitted on March 10, 2011 and approved on March 17, 2011 stated the following:
"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 occurs 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."
An interview with the facility director on June 14, 2011 confirmed the findings.
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Plan of Correction
Facility director again clarified required quarterly time frames for case consultations with staff and clinical supervisor.
Training did occur on March 18, 2011 but documentation was not properly placed in training section. It is there now.
The next 4 supervisory sessions, July 1-July 22, 2011 will focus on client record documentation. This focus will be reflected in supervisory records which facility director will initial after reviewing charts discussed.
After this period, charts will be closely monitored at weekly supervision/chart review by clinical supervisor who will report any defiencies to staff and facility director. As of August 1,2011 clinical supervisor will provide training on a quarterly basis with documentation provided as well as suggest outside traings that supervisor feels will prove beneficial. Facility director is responsible that the above takes place. |
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 four of four discharge records reviewed.
The findings include:
Eight client records were reviewed on June 14, 2011. Discharge summaries where required in four discharge records reviewed, #5, 6, 7 and 8. 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.
This is a repeat citation.
The facility was previously cited for noncompliance with this standard during the January 26, 2011 licensing inspection. The facility's plan of correction submitted on March 10, 2011 and approved on March 17, 2011 stated the following:
"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."
An interview with the facility director on June 14, 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
Discharge summary was revised on 6/15/2011 to reflect client's reason for treatment, response to treatment, is now being utilized.
Training did take place on March 18, 2011 but documentation was placed in wrong section of personnel file. It is now in training section.
The next 4 supervisory sessions, July 1-July 22,2011, will focus on client record keeping. Facility director will review supervisory record and initial after reviewing charts discussed. |
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 four closed client records reviewed.
The findings include:
Eight client records reviewed on June 14, 2011. Follow-up information was required in four closed client records, #5, 6, 7 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.
Client #5 was admitted on December 29, 2010 and discharged on April 11, 2011. The date of the follow-up was documented the same day the client was discharged on April 11, 2011. The follow-up is to be conducted within 7 days after discharge if being referred or 30 days following their discharge date. The follow-up should have taken place either by May 11, 2011 or within 7 days of the client's appointment if referred, but after the discharge date of April 11, 2011.
Client #6 was admitted on December 17, 2010 and discharged on June 1, 2011. The date documented for the follow-up contact was the same day the client was discharged, June 1, 2011. The follow-up is to be conducted within 7 days of the discharge date if referred and within 30 days following their discharge date. The follow-up should have taken place either by July 1, 2011 or within 7 days of the client's appointment if referred, but after June 1, 2011.
Client #8 was admitted on February 22, 2011 and discharged on April 21, 2011. As of the date of the inspection the follow-up was documented for April 11, 2011 ten days before the client was discharged.
This is a repeat citation.
The facility was previously cited for noncompliance with this standard during the January 26, 2011 licensing inspection. The facility's plan of correction submitted on March 10, 2011 and approved on March 17, 2011 stated the following:
"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."
An interview was conducted with the facility director on June 14, 2011 and it was confirmed that follow-up contact was not documented in client records #5, 6 and 8.
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Plan of Correction
Facility director discussed follow-up information with staff on June 15,2011.
Procedural errors were responsible for early follow-ups. Procedure was changed on 6/15/2011.
All clients will be contacted within 7 days if being referred or 30 days of discharge date.
Clinical supervisor will review all discharges in the month of July to verify correct procedures are being followed correctly. Clinical supervisor will report staff progress to facility director.
Four supervisory sessions focusing on client record keeping are being held from July 1 -July 22, 2011. They will be noted in record of supervision which facility director will initial after reviewing records being examined.
After this period, charts will be closely monitored at weekly supervision/chart review by clinical supervisor who will report any defiencies to staff and facility director. As of August 1,2011 clinical supervisor will provide training on a quarterly basis with documentation provided as well as suggest outside traings that supervisor feels will prove beneficial. Facility director is responsible that the above takes place.
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