INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on June 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. The first-floor bathroom did not have a mechanical dryer or individual paper towels available.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 13, 2022 annual licensing inspection.
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Plan of Correction
The paper towels holder was replaced on day of inspection. House Managers will check to ensure it is on the wall daily and complete checklist to provide to Facility Manager every Friday. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. The third-floor emergency exit door would not open.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 13, 2022 annual licensing inspection.
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Plan of Correction
Director called security company who came and repaired magnetic lock (paperwork on file). House Mangers will check the door daily on third shift to ensure the door is in good working order. Picture sent to inspector of working door. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on two of three applicable client records reviewed, the facility failed to provide documentation of the administration of medication according to the facility policy and procedure manual. The policy and procedure manual indicates that both the client and staff will initial the medication administration record for documenting medication.
Client # 2 was admitted on April 7, 2022 and was still active at the time of the inspection.
Two medications prescribed to be taken one tablet twice daily was not documented, by initial from staff and client, on the medication administration record for May 17, 20, 22, 27, 2022-April 8, 10, 12, 14, 15, 17-19, 21, 23, 24, 27, 2022.
Three medications prescribed to be taken at bedtime was not documented, by initial from staff and client, on the medication administration record for May 7-17, 21, and 28, 2022- May 6-8, 11-16, 20, 2022-May 6, 8, 10-12, 14-17, 2022.
Client # 3 was admitted on April 18, 2022 and was still active at the time of the inspection.
Two medications prescribed to be taken one tablet daily was not documented, by initial from staff and client, on the medication administration record for April 20, May 1, 2022-April 20, May 4, 7-9, 11, 13-15, 2022.
One medication prescribed to be taken one tablet twice daily was not documented, by initial from staff and client, on the medication administration record for May 1, 2, 4, 6-22, 24, 2022.
One medication prescribed to be taken at bedtime was not documented, by initial from staff and client, on the medication administration record for May 18-25, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 13, 2022 annual licensing inspection.
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Plan of Correction
The nurse changed the medication sheet for clarity and she will check the medication sheets for compliance daily. Also all staff were retrained by the nurse and have signed a form stating they understand how to observe and documents self medication process. |
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 two of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 30 days by letter.
Client # 4 was admitted on March 16, 2022 and discharged on March 23, 2022. There was no follow-up information documented in the client record.
Client # 6 was admitted on February 23, 2022 and discharged on March 16, 2022. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 13, 2022 annual licensing inspection.
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Plan of Correction
All staff were trained on the need to complete the follow up letter. The intake coordinator will be responsible for sending the letter and documenting the form in the clients file monthly. Random weekly chart audits by nurse/counselor will confirm compliance in this area. All closed charts for the last 6 months were pulled and the letter was sent for follow up. |