INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPANISH AMERICAN CIVIC ASSOCIATION FOR EQUALITY, INC 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, it was observed that the facility failed to provide either an operable soap dispenser and either individual paper towels or a mechanical dryer in each client's bathroom. There was no soap in the second floor back bathroom, no paper towels in the second floor front bathroom and no soap or paper towels in the group room bathroom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/29/25 after the DDAP audit staff went to all bathrooms and placed paper towels on all dispensers that were missing them. They also placed full hand soap dispensers where they were missing. On 1/30/2025 it was added into the residential aide job duties to complete daily rounds to add any soap and/or paper towels where needed. SUD Program Director will review that these check off tasks have been completed daily. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on January 29, 2025, the facility failed to ensure cold food was at or below 40F. The temperature of the refrigerator in the basement registered 46F.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
On 1/29/25 after DDAP Audit, maintenance was called in to adjust the temperature for the refrigerator. Temperature was then checked and has been between 36 and 40 degrees. New temperature log was created that same day and posted next to the refrigerator for completion on every shift by nurse on day shift and by residential aide on second and third shift. This has been added the the staff check off list for daily completion. SUD Director will monitor completion weekly. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from February - December 2024, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of July - October, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/30/25 a 2025 fire drill schedule was created. The fire drill schedule will remain confidential and only available to those needing said information. Effective 2/1/25 unannounced fire drills will be completed on scheduled days. Immediately after each fire drill a scan copy of completed drill documentation will be scanned over to the Quality Assurance and Compliance Officer for digital record keeping as a back up of completion and documentation. SUD Program Director will be responsible for ensuring the scheduled fire drills are completed and scanned over to QA&C officer. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies within seven days of employment.
Employee #1 was hired on September 3, 2024 as the Project Director/Facility Director and was still in the position as of the date of the inspection. The training was completed on September 16, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 1/30/2025, SUD Program Manager will ensure all newly hired staff have completed the emergency procedure training within 7 days of hire. Quality Assurance and Compliance Officer will ensure this requirement is completed withing 7 days by reviewing and requesting all completed trainings on day 6 of new hire. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from February - December, 2024 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on May 16, 2024 and none has been documented since that date.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/30/25 a fire drill schedule was created for 2025, on this schedule has clearly identified when there will be an un-announced fire drill during the sleep hours every 6 months. SUD Manager will be responsible for ensuring this schedule will be followed. Quality Assurance and Compliance Officer will follow up with SUD Director for completion. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #5 was admitted on August 28, 2024 and was discharged on November 15, 2024. A treatment plan update was completed on October 1, 2024 and an update was due no later than November 1, 2024; however, none was completed.
Client #6 was admitted on September 6, 2024 and was discharged on December 24, 2024. A treatment plan update was completed on October 12, 2024 and an update was due no later than November 12, 2024; however, it was not completed until November 25, 2024.
Client #7 was admitted on August 1, 2024 and was discharged on November 19, 2024. A treatment plan update was completed on October 10, 2024 and an update was due no later than November 10, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2/11/2025 a meeting was held with the clinical team (counselors) were the lack of treatment plan updates was addressed. There was an issue identified with staff turnover and new counselors being unaware of missing treatment plans. As of 2/11/2025, counselors will keep track on a spread sheet of when client treatment plans are due, counselors will submit this spread sheet to SUD Director who will review charts 1 week prior to due date for reminder to counselors of due dates. Also, on 3/10/2025, we will be implementing new EMR system which will be easier to track when sessions and treatment plans are due. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven records reviewed. The facility's policy and procedures manual states that case consultations must be completed each week.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/3/2025 SACA policy in regards to case consultation reviews was updated to state that that weekly case consults are completed. However, case presented will include any new admissions, discharges, and any treatment plan updates or changes. SUD Director will ensure during case consult review to remind counselor to review any clients that fall under these categories. |
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 a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of one applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed within 7 days following discharge.
Client #5 was admitted on August 28, 2024 and discharged on November 15, 2024. A follow up was due no later than November 22, 2024; however, none was not completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SACA policy was updated on 2/3/25 to reflect follow up to be made to all client regardless of type of discharge. If unable to contact the discharged client the outreach person will document this as well. SUD Director will ensure this update is followed by outreach staff and documentation is completed with the outcome, as will be evidenced by weekly chart audits. |