INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the inspection, Nuestra Clinica Rehabilitation was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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Plan of Correction
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
A physical plant inspection was conducted on February 6, 2017. Based on this inspection, the facility fail to ventilate toilet and wash rooms by exhaust fan or window. The bathroom in Room 2B did not have a ventilation exhaust fan or window.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director contacted maintenance supervisor who hired electrician to do the installation of fan. Work to be completed by April 8, 2017. The director will ensure the maintenance department installs fan. All bathrooms will be checked monthly to ensure working ventilation is in each bathroom. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
A review of client records was conducted on February 6, 2017. Based on this review, the facility failed to ensure the verification of the client's acceptance or refusal of a copy of the release form in three client records.
Client #2 was admitted on December 20, 2016 and was still receiving services the day of the review. The consent to release information form to a court or legal entity that was signed and dated December 5, 2016 failed to verify the client's acceptance or refusal of the form.
Client #3 was admitted on November 17, 2016 and was still receiving services the day of the review. The consent to release information form to the Department of Welfare that was signed and dated November 17, 2016 failed to verify the client's acceptance or refusal of the form.
Client #8 was admitted on June 13, 2016 and discharged on June 20, 2016. The consent to release information form to a court or legal entity that was signed and dated June 13, 2016 failed to verify the client's acceptance or refusal of the form.
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Plan of Correction
Intake worker and counselors were retrained on February 10, 2017 by director. Clinical supervisor will audit charts for compliance weekly, and director will audit monthly for compliance for the next 2 months then monthly going forward. |