INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2012 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
The findings include:
On January 19, 2012 the Staffing Requirements Facility Summary Report was reviewed.
Four employees were required to have documentation of the required HIV/AIDS and TB/STD training. The facility failed to provide documentation of the required HIV/AIDS training for employee # 4.
Employee # 4 was hired 10/31/05.
Employee # 4 is a psychiatrist.
HIV/AIDS training was to be completed within the first 2 years of employment, by 10/31/07.
At the time of review on 1/19/12, the facility failed to document completion of 6 hours HIV/AIDS training.
The project director did not dispute the findings.
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Plan of Correction
As of 3/1/2012 Employee #4 will undergo a reduction of hours at this facility. As of 3/1/2012 Employee #4 will no longer provide services to drug and alcohol clients at this facility.
It is the responsibility of the project director to ensure that all staff receive the required training. The agency will provide bi-annual HIV/AIDS and tuberculosis, sexually transmitted diseases and otherhealth related topics training. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facility's staff schedule from January 2 - 20, 2012 and copies of staff CPR and First Aid cards, the facility failed to provide a sufficient number of staff persons trained in CPR during the project's hours of operation.
The findings include:
The facility's hours of operation are Monday through Friday 8:30 AM - 5:00 PM.
On January 20, 2012 copies of staff CPR and First Aid cards along with the January 2012 work schedule as provided by the facility were reviewed.
Based on the work schedule provided by the facility, the facility failed to provide CPR coverage from 8:30 AM to 5:00 PM on January 3, 4, 5, 9, 10, 11, 12, 16, 17, 18, and 19.
Based on the work schedule provided by the facility, the facility failed to provide CPR coverage from 8:30 AM - 12: 30 PM on January 6, 13, and 20.
Based on the work schedule provide by the facility, the facility failed to provide CPR coverage from 2:30 PM - 5:00 PM on January 6, 13, and 20.
In addition, the facility provided CPR and First Aid cards for employee # 1, 2, and 3.
Employee # 1 is the project director.
Employee # 1 works full time Monday through Friday from 8:30 AM to 5 PM.
Employee # 1's CPR card expired 12/13/11.
Employee # 2 is the clinical supervisor.
Employee # 2 has current CPR certification; however, employee # 2 works part time on Friday from 12:30 PM to 2:30 PM.
Employee # 3 is a counselor assistant.
Employee # 3 works full time Monday through Friday from 8:30 AM to 5 PM.
Employee # 1's CPR card expired 12/13/10.
The project director and assistant director confirmed the findings.
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Plan of Correction
Employee #3 completed CPR training on 1/19/12 and docuemtnation was sent to the licensing board to confirm training was completed. Office manager completed training on January 24th at the local Red Cross.
It is the project director's responsibily to ensure that there is coverage with CPR/First Aid available at all times. The Project director will review all personnel charts on a quarterly basis and schedule training with a in-house trainer 3 months before
expiration date. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
On January 19, 2012 a physical plant inspection was conducted at 8:30 AM and another physical plant inspection was conducted at 3:15 PM.
The facility has one ladies room on the second floor which is used by clients and visitors.
The ladies room located on the second floor has two stalls.
At 8:30 AM one out of two stalls in the ladies room was not clean or sanitary as the toilet was not functional and the trash can was overflowing.
At 3:15 PM the toilet had not been cleaned.
The office manager and the assistant director confirmed the findings.
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Plan of Correction
The Project Director spoke with the Housing Coordinator in charge of maintenance on 2/3/2012 who assured the project director that the bathrooms are cleaned regularly daily.
The project director related the incident on the day of inspection. The project director will take random daily checks of visitor and staff bathrooms and report to the housing coordinator any unclean findings to the housing coordinator who will have the bathroom cleaned immediately.
The project director will then recheck.
Person responsible for maintenance is the housing coordinator, person responsible for confirmation of maintenance will be the project director.
The project director checked all bathrooms on 2/3/12 and found them clean and functional. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
On January 19, 2012, two personnel records requiring documentation that staff had been instructed in the use of a fire extinguisher upon employment were reviewed.
The facility failed to document the completion of fire extinguisher training upon staff employment in two of two personnel records, # 2 and 5.
Employee # 2 was hired on 1/14/11.
The training was due upon employment, the training was not documented at the time of review on 1/19/12.
Employee # 5 was hired on 11/1/11.
The training was due upon employment, the training was not documented at the time of review on 1/19/12.
The project director confirmed the findings.
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Plan of Correction
Employee #2 received fire extinguisher training on date of hire 1/14/11 but document was misfiled in employee's personnel record.
Employee #5 was trained in the use of fire extinguisher on 1/20/12.
In the future it is the responsibility of the project director to ensure fire extinguisher training occurs upon the first day of employment before the employee starts their duties.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
On January 19, 2012, five personnel records requiring documentation to verify that all personnel on all shifts were trained to perform assigned tasks during emergencies were reviewed.
The facility did not document that emergency training was provided upon employment in two out of five personnel records, # 2 and 5.
Personnel # 2 was hired on 1/14/11, but verification of this training was not documented at the time of review on 1/19/12.
Personnel # 5 was hired on 11/1/11, but verification of this training was not documented at the time of review on 1/19/12.
The project director confirmed the findings.
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Plan of Correction
Employee #2 received fire safety and emergency upon date of employment on 1/14/2011 but documentation was misfiled in personnel chart.
Employee #5 received fire safety and emergency training on 1/20/12.
It is the responsibility of the project director to ensure this training takes place upon employment for any new hires before they begin their regular duties. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the project's annual report, the facility's web page and an interview with the Project Director and Assistant Director, the facility failed to make available to the public the 2010-2011 annual report by the end of the facility's fiscal year.
The findings include:
The facility's annual report and web were reviewed on January 19, 2012.
The Project Director and Assistant Director stated that the board of directors uploaded the annual report to the web site on January 18, 2012. However, the annual report available on line was the annual report for the 2009-2010 fiscal year not the 2010-2011 fiscal year.
The Project Director and Assistant Director confirmed that the 2010-2011 annual report was not made available to the public by the end of the fiscal year.
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Plan of Correction
The annual report was posted on the SACA website on January 19, 2012 and the the governing body has agreed to make this report available to the the public by the end of the fiscal year beginnning with June 30th, 2012 and continuing with this posting date annually. The responsibility for compliance is the CEO. |
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 a review of the facility's policy and procedure manual, the facility failed to document a psychosocial evaluation that was evaluative.
The findings include:
The facility's policy titled "Biopsychosocial" states:
A comprehensive biopsychosocial assessment will be completed on each individual entering treatment at Nuestra Clinica. It shall be fully completed by the second assessment session.
It shall provide a composite picture of the client.
On January 19, 2012, ten client records were reviewed for documentation of a psychosocial evaluation.
The facility failed to document an evaluative psychosocial evaluation in ten of ten records reviewed.
Client # 1 was admitted to the program on 10/26/11.
The psychosocial evaluation was documented on 11/15/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's support systems and coping mechanisms.
Client # 2 was admitted to the program on 12/22/11.
The psychosocial evaluation was documented on 1/9/12.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's support systems and coping mechanisms.
Client # 3 was admitted to the program on 9/22/11.
The psychosocial evaluation was documented on 9/29/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's support systems and coping mechanisms.
Client # 4 was admitted to the program on 11/14/11.
The psychosocial evaluation was documented on 11/21/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's support systems and coping mechanisms.
Client # 5 was admitted to the program on 10/14/11.
The psychosocial evaluation was documented on 10/20/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's coping mechanisms.
Client # 6 was admitted to the program on 7/19/11 and discharged on 12/15/11.
The psychosocial evaluation was documented late on 8/24/11.
In addition, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's support systems and negative factors.
Client # 7 was admitted to the program on 8/23/11 and discharged on 12/19/11.
The psychosocial evaluation was documented on 8/31/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's assets/strengths, support systems, and coping mechanisms.
Client # 8 was admitted to the program on 7/13/11 and discharged on 10/6/11.
The psychosocial evaluation was documented on 7/20/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's support systems and coping mechanisms.
Client # 9 was admitted to the program on 6/20/11 and discharged on 6/28/11.
The psychosocial evaluation was documented on 6/28/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's assets/strengths and support systems.
Client # 10 was admitted to the program on 10/7/11 and discharged on 1/17/12.
The psychosocial evaluation was documented on 10/24/11.
However, the facility failed to document an evaluative psychosocial.
The clinician failed to provide an assessment regarding the client's support systems.
The project director did not dispute the findings.
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Plan of Correction
The project director, clinical supervisor, and assistant counselor met to review this observation. We began using a new model of a fully completed composite picture of which we incorporated elements in a new document which the assistant counselor will begin using as of this date 2/3/2012. It will act as a guide to cover assessment of client's support systems and coping mechanisms as well as negative factors which were missed in the inspected client records.
The clinical supervisor will check Biopsychocial assessment at each weekly supervision and report to project director progress in this area. In addition project director will perform random monthly chart reviews to ensure compliance.
The assistant counselor is responsible for this evaluation, the clinical supervisor is responsible for assisting the counselor in his training, and the project director is responsible for oversseeing this team effort at improvement. |