INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2015 of site inspection Nuestra Clinica of SACA Drug and Alcohol program 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.
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Plan of Correction
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709.28(c) 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:
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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 eleven client records.
The findings included:
Eleven client records were reviewed on November 17, 2015. The facility failed to document on the consent to release forms the purpose of the release in client records, #1, 2, 3 and 5. The following consents dates in question are:
Client record #1 consent to release dated August 25, 2015
Client record #2 consent to release dated January 14, 2015
Client record #3 consent to release dated December 10, 2015
Client record #5 consent to release dated August 6, 2015
Additionally, the facility checked the other box on the consent to release form dated May 12, 2015, but failed to document what was being released.
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Plan of Correction
The consents were corrected in the client records.
Clinical Supervisor and director retrained staff on completion of consent forms. If other is chosen the staff was advised to complete reason for "other" choice. If not that line is crossed out so nothing can be added without client consent. Clinical supervisor will do bi-weekly audits to ensure compliance. Director will do monthly audits to follow up as well for the next 6 months. |
709.92(a) 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:
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan in three of eleven client records.
The findings include:
Eleven records were reviewed on November 17, 2015. The facility failed to document an individual treatment and rehabilitation plan in client records, #9, 10 and 11. The individual treatment and rehabilitation plans were identical from goals/time frames, support services and type/frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and clinical supervisor held a training on treatment planning with staff. The clinical supervisor will perform weekly supervision and chart audits around treatment plans and the need for personalization for the next 6 months.
The director will perform monthly audits for the next 6 months to ensure compliance |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates in seven of eleven records reviewed.
Findings
Eleven client records were reviewed on November 17, 2015. The facility failed to document in the treatment plan updates in records, #2, 3, 5, 7, 8, 10 and 11. The treatment plans updates were just copies of the comprehensive treatment plan with no update on each plan.
Client #2 was admitted on January 14, 2015 and discharged on July 2, 2015. The comprehensive treatment plan was completed on January 28, 2015. The facility failed to document updates to client #2's treatment plan dated January 28, 2015.
Client #3 was admitted on December 10, 2014 and discharged on August 31, 2015. The comprehensive treatment plan was completed on January 5, 2015. The facility failed to document updates to client #3's treatment plan dated January 5, 2015.
Client #5 was admitted on August 6, 2015. The comprehensive treatment plan was completed on August 20, 2015. The facility failed to document updates to client #5's treatment plan dated August 20, 2015.
Client #7 was admitted on May 12, 2015. The comprehensive treatment plan was completed on May 12, 2015. The facility failed to document updates to client #7's treatment plan dated May 12, 2015.
Client #8 was admitted on August 5, 2015. The comprehensive treatment plan was completed on August 19, 2015. The facility failed to document updates to client #8's treatment plan dated August 19, 2015.
Client #10 was admitted on July 13, 2015 The comprehensive treatment plan was completed on August 3, 2015. The facility failed to document updates to client #10's treatment plan dated August 3, 2015.
Client #11 was admitted on March 30, 2015 and discharged on September 28, 2015. The comprehensive treatment plan was completed on April 13, 2015. The facility failed to document updates to client #11's treatment plan dated April 13, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and clinical supervisor held a training on treatment planning with staff. The clinical supervisor will perform weekly supervision and chart audits around treatment plan and the regulations around updates for the next 6 months.
The director will perform monthly audits for the next 6 months to ensure compliance
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