INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 6, 2023 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:
|
Plan of Correction
|
704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
|
Observations
Based on a discussion with the project director, the facility was only able to provide a staff schedule for the week of May 8-14, 2023, therefore the project is unable to provide current documentation of 24 hour staff coverage.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The facility director will create a weekly schedule for 24/7 coverage of all staff by 3/1/24. This schedule will be updated weekly.
The project director will ensure this is being completed by 3/4/24, and weekly afterwards. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of personnel records, the facility failed to document that the facility director met both the education and experiential qualifications for the position.
Employee #2 was hired on August 22, 2023 as the facility director. The employee has no documented program planning experience or supervision experience.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Employee #2's employment with SACA was terminated on 1/24/24.
The project director will ensure future interviews of the position of facility director will meet the qualifications as per DDAP regulations, including program planning experience and supervision experience amongst the others. This will begin immediately, 1/29/24. |
704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
|
Observations
Based on a review of personnel records and the Staffing Facility Summary Report, the facility failed to document and complete a positive assessment of the counselors assistants individual skill level prior to the assignment of a full caseload.
Employee # 5 was hired as a counselor assistant on February 9, 2023. There was no documented positive assessment in the employee record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will complete a positive assessment of the counselor assistant's individual skill level by 3/4/24.
The project director will audit employee files monthly to ensure ongoing compliance. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete a written semiannual performance evaluation based upon measurable performance standards for the counselor assistant.
Employee #5 was hired on February 9, 2023 and was due to have an evaluation by August 9, 2023.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The project director will complete a written, semiannual performance evaluation with measurable performance standards for employee #5 by 3/4/24.
The project director will audit employee files on a monthly basis to ensure compliance moving forward. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an assessment of staff training needs.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of an assessment of staff training needs. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an overall plan for addressing these needs.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of an overall plan for addressing these needs. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of a mechanism to collect feedback on completed trainings.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of a mechanism to collect feedback on completed trainings This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will update the policy and procedure manual to include a comprehensive staff development program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in five of five employee records reviewed.
Employee #1 was hired on September 11, 2023 as the Project Director and was still in the position as of the date of the inspection. There was no training plan documented.
Employee #2 was hired on August 22, 2023 as the facility director and was still in the position as of the date of the inspection. There was no training plan documented.
Employee #3 was hired on September 27, 2022 as a counselor and was still in the position as of the date of the inspection. There was no training plan documented.
Employee #4 was hired on October 26, 2021 as a counselor assistant and was still in the position as of the date of the inspection. There was no training plan documented.
Employee #5 was admitted on February 9, 2023 as a counselor assistant and was still in the position as of the date of the inspection. There is no training plan documented.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Individual training plans for the noted staff will be written and completed by the project director by 3/4/24.
The project director will audit employee files on a monthly basis to ensure that compliance remains. This will also begin on 3/4/24. |
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor assistant on October 26, 2021 and was due to have the communicable disease trainings no later than October 26, 2022. There was no documentation in the personnel file of the completion of TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will ensure that the noted employees will receive the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD by 3/4/24. The certificates will be placed in the respective employee's files.
The project director will audit employee files on a monthly basis to ensure continued compliance. |
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.
|
Observations
Based on a discussion with the project director, the facility was only able to provide a staff schedule for the week of May 8-14, 2023, therefore the project is unable to provide current documentation of CPR coverage.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will ensure that employees are current with their CPR certifications by 3/4/24. If not, the employees will be given 30 days to complete said certification.
The project director will audit employee charts monthly to ensure compliance. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistant in employee #4's employee record.
Employee #4 was hired on October 26, 2021 as a counselor assistant and was still in the position as of the date of the inspection. There was no training hours documented.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will ensure that employee #4 has the required amount of training hours by 3/4/24.
Project director will audit employee files on a monthly basis to ensure that compliance remains moving forward. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms on both the second and third floor. Additionally, employee #4 office walls do not extend from the floor to the ceiling allowing counseling sessions to be heard from outside of the room.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #4's office has already been moved out of the area that was non-compliant. She is currently in an office with a door that shuts.
The facility has also ceased camera usage when group therapy occurs.
The project director will begin a monthly check on 3/4/24 to ensure staff are not using the cameras during group hours. |
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.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer on the second floor bathroom.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The house manager supervisor will ensure that each client bathroom is suitably provided with individual paper towels on every floor. This will begin on 3/4/24.
The project manager will ensure that paper towels are provided in every floor bathroom through a random, monthly audit beginning on 3/4/24. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure three employees received the required training in the use of the fire extinguishers upon employment.
Employee #1 was hired on September 11, 2023 for the position of project director and was still employed at the time of the inspection. No training was documented in the employee record.
Employee #2 was hired on August 22, 2023 for the position of facility director and was still employed at the time of the inspection. No training was documented in the employee record.
Employee #5 was hired on February 9, 2023 for the position of counselor assistant and was till employed at the time of the inspection. No training was documented in the employee record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project manager will ensure that each noted employee completes fire extinguisher training by 3/4/24.
The project manager will audit employee files every month to ensure compliance moving forward. |
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training to perform assigned tasks during emergencies.
Employee #1 was hired on September 11, 2023 for the position of project director and was still employed at the time of the inspection. No training was documented in the employee record.
Employee #2 was hired on August 22, 2023 for the position of facility director and was still employed at the time of the inspection. No training was documented in the employee record.
Employee #5 was hired on February 9, 2023 for the position of counselor assistant and was till employed at the time of the inspection. No training was documented in the employee record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project manager will ensure that each noted employee completes training regarding their role in an emergency situation at the facility by 3/4/24.
The project manager will audit employee files every month to ensure compliance moving forward. |
709.22 (b) (3) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(3) Documenting the project ' s organizational structure.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document the project ' s organizational structure.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will update the policy and procedure manual to include an organizational structure of the project. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have the project director prepare, annually update and sign a written manual.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will ensure the policy and procedure manual is completed with signatures by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.24 (a) (2) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Identification of the treatment models and practices utilized by the project.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written plan identifying the treatment models and practices utilized by the project in their residential services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan identifying the treatment models and practices utilized by the project in their residential services. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written procedures for the management of treatment/rehabilitation services for clients.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for procedures for managing treatment/rehabilitation services for clients. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt written procedures for referral outlining cooperation with other services providers including, but not limited to, provision for access to emergency services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for referral outlining cooperation with other service providers, including, but not limited to, provision for access to emergency services. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures for utilization of volunteers.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for utilization of volunteers. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures for rules of conduct.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for rules of conduct. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of employee records, the facility failed to follow their policy regarding annual written individual staff performance evaluations being completed at 6 month and 12 months for employee #3 and #4.
Employee #3 was hired as a counselor on September 27, 2022 and was still in that role at the time of the inspection. Their employee record failed to contain documentation of an annual written individual staff performance evaluation for both 6 months and 12 months.
Employee #4 was hired as a counselor assistant on October 26, 2021and was still in that role at the time of the inspection. Their employee record failed to contain documentation of an annual written individual staff performance evaluation for both 6 months and 12 months.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedures manual to better reflect current staff performance evaluation practices, which is yearly. This will occur on 3/4/24.
If not already completed, the project director will ensure that the noted employees have current evaluations in their employee charts by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt written job descriptions for project positions.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include written job descriptions for project positions. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written procedures to address confidentiality of client identity and records. The policy and procedures did not include identification of the person responsible for maintenance of client records and procedures on keeping client records and identity confidential.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
The project director will update the policy and procedure manual to include written identification of the person responsible for the maintenance of client records and procedures for keeping client records and identity confidential. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written procedures for identification of project staff having access to records, and the methods by which staff gain access.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include written procedures for identifying project staff having access to records and the methods by which staff gain access. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in ten out of ten records reviewed. The client records had documentation of disclosure to a government agency ; however there were no informed and voluntary consent to disclose information forms signed by the client.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project director will conduct a training with the intake specialist to ensure proper documentation regarding consents. This will be completed by 3/4/23.
The project director will audit client charts randomly to ensure compliance. This will occur on a monthly basis.
If clients are still active, the project director will ensure current project staff complete new consents for cited clients. This will be completed by 3/4/24. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include a client receiving care or treatment under section 7 of the act (71 P.S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include client rights, especially those receiving care or treatment under section 7 of the act (71 P.S. 1690.107), shall retain civil rights and liberties except as provided by statute. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include client rights, including the project may not discriminate in providing services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to ensure clients have the right to inspect their records. The project, facility, or clinical director may temporarily remove portions of the records before the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for eliminating sections shall be documented in the record. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include clients have the right to appeal a decision limiting access to their records to the director. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include that clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include that Clients have the right to submit rebuttal data or memoranda to their own records.This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to accurately state the regulation in their manual, as their policy required physicians to provide written authentication to a verbal order within seven days. The regulation for required the written authentication to occur within 3 business days.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include that physicians must provide written authentication to a verbal order within three business days. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.32 (c) (2) 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:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures to include the secure storage of drugs in accordance with regulations.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include the secure storage of drugs in accordance with regulations. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures to include the inspection of storage areas that ensure compliance with laws. The policy and procedures did not include what is to be verified through the inspection, storage of disinfectants and external use drugs, drugs requiring special conditions, removal of outdated drugs and copies of drug-related regulations availability in appropriate areas.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include inspecting storage areas that ensure compliance with laws. The policy and procedures will consist of what is to be verified through the inspection, storage of disinfectants and external use drugs, drugs requiring special conditions, removal of outdated medications, and copies of drug-related regulations available in appropriate areas. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
|
Observations
Based on a review of the facility ' s written policy and procedures regarding all medications used by clients, the facility failed to include policies for control and accountability of drugs, including who is authorized to remove drug. Additionally the facility also failed to ensure that missed medications were documented in medical records four out of seven client records reviewed.
Client #1 was admitted on August 1, 2023 and was still active at the time of the inspection. The medication administration record failed to document missed medication of Vistaril 25 mg on August 9th, 12th, 23rd, 24th, and 26th , 2023.
Client 2 was admitted on August 15, 2023 and was still active at the time of the inspection. The medication administration record failed to document missed medications of Seroquel 100 mg, Remeberam 15 mg, Abilify 10 mg, and Lamiteal 25 mg on October 4th and 5th, 2023.
Client #3 was admitted on August 15, 2023 and was still active at the time of the inspection. The medication administration record failed to document missed medication of Trazodone 50 mg on October 4th and 5th, 2023.
Client #8 was admitted on August 29, 2023 and discharged on October 31, 2023. The medication administration record failed to document missed medication of Lisinopril 40 mg on September 17th and 24th, 2023.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The project's medical staff will train all staff who are responsible for administering and documenting medication pass. This training will occur by 3/4/24.
Project director and conduct monthly audits of medication log and report any medication errors to DDAP through the incident reporting system.
The project director will update the policy and procedure manual to include policies for control and accountability of drugs, including who is authorized to remove the drugs. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures to include the security of drugs including loss, theft or misuse of drugs.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include policies on the security of drugs, including loss, theft, or misuse of drugs. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include physical assault or sexual assault by staff or a client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include policies responding to unusual incidents, including physical assault or sexual assault by staff or a client. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include policies responding to unusual incidents, including the selling or use of illicit drugs on the premises. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include serious injury due to trauma, suicide, medication error or unusual circumstances.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents including serious injury due to trauma, suicide, medication error, or unusual circumstances. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents to include theft, burglary, break-in or similar incident at the facility. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include event at the facility requiring the presence of policy, fire or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents and events at the facility requiring the presence of police, fire, or ambulance personnel. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include outbreak of a contagious disease requiring CDC notification.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents, including outbreaks of a contagious disease requiring CDC notification. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents, including prompt review and identifying the causes directly or indirectly responsible for the unusual incident. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include implementation of a timely and appropriate corrective action plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents and implementing a timely and appropriate corrective action plan. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
The project director will update the policy and procedure manual to include responding to unusual incidents and ongoing monitoring of the corrective action plan. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes criteria for admission.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for intake and admission, including criteria for admission. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.51(a)(2) LICENSURE Treatment Methodology
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes treatment methodology.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for providing for intake and admission,, including treatment methodology. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.51(a)(3) LICENSURE Tx Completion Requirements
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes requirements for completion of treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for intake and admission, including requirements for treatment completion. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes involuntary discharge/termination criteria.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for intake and admission, including involuntary discharge/termination criteria. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of eight client records reviewed.
Client #1 was admitted on August 1, 2023 and was still active at the time of the inspection. A treatment plan update was completed on September 12, 2023 and the next update was due no later than October 12, 2023; however, there was no update documented in the record at the time of the inspection.
Client #2 was admitted on August 15, 2023 and was still active at the time of the inspection. A treatment plan update was completed on September 21, 2023 and the next update was due no later than October 21, 2023; however, there was no update documented in the record at the time of the inspection.
Client #3 was admitted on August 15, 2023 and was still active at the time of the inspection. A treatment plan update was completed on September 25, 2023 and the next update was due no later than October 25, 2023; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on July 19, 2023 and was discharged on October 23, 2023. A treatment plan update was completed on July 24, 2023 and the next update was due no later than August 24, 2023; however, there was no update documented in the record until September 24, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will provide a training to the staff regarding treatment plan update timeframes. A sign-in sheet will be provided to show proof of attendance and compliance. This training will occur by 3/4/24.
The project director will complete a monthly audit of charts to ensure compliance with treatment plan update dates. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in seven out of the eight records reviewed.
Client #1 was admitted on August 1, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 12, 2023, indicated 1 individual session weekly and groups daily. The record of service and progress notes indicated that the client had received no individual sessions since August 19, 2023 and no group sessions since October 31, 2023.
Client #2 was admitted on August 15, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 23, 2023, indicated 1 individual session weekly and groups daily. The record of service and progress notes indicated that the client had received no individual sessions since October 18, 2023 and no group sessions since October 31, 2023.
Client #3 was admitted on August 15, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 25, 2023, indicated 1 individual session weekly and group sessions daily. The record of service and progress notes indicated no group sessions since October 31, 2023
Client #4 was admitted on September 21, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated September 30, 2023, indicated 1 individual weekly and groups daily. The record of service and progress notes indicated that the client had received individual sessions bi-weekly during the month of October and no group sessions since October 31, 2023.
Client #6 was admitted on July 19, 2023 and was discharged on October 23, 2023. The comprehensive treatment plan, dated July 24, 2023 indicated 1 individual session weekly and group sessions daily. The record of service and progress notes indicated that the client did not receive an individual session for the week of August 20-26, 2023.
Client #7 was admitted on June 29, 2023 and was discharged on September 27, 2023. The comprehensive treatment plan, dated July 5, 2023 indicated 1 individual session weekly and group sessions daily. The record of service and progress notes indicated that the client did not receive an individual session for the weeks of July 23-29th, 2023, and September 10-23, 2023.
Client #8 was admitted on August 29, 2023 and was discharged on October 31,2 023. The comprehensive treatment plan, dated September 7, 2023 indicated 1 individual session weekly and group sessions daily. The record of service and progress notes indicated that the client did not receive an individual session for the weeks of October 8-29th, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project held a training with all project staff regarding this issue on 11/14/23. A sign in sheet is available if you would like. This training addressed the issues which were audited.
The project director will audit files on a monthly basis to ensure that treatment services are aligned with the client's individual treatment plan. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one out of three records reviewed.
Client #8 was admitted on August 29, 2023 and was discharged on October 31, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will review the need for aftercare services with project staff by 3/4/24. A sign-in sheet will be available to show proof of discussion.
Project director will audit discharged files on a monthly basis to ensure that compliance is current. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in three out of six records reviewed.
Client #7 was admitted on June 29, 2023 and was discharged on September 27, 2023
Client #8 was admitted on August 29, 2023 and was discharged on October 31, 2023
Client #10 was admitted on July 19, 2023 and was discharged on July 24, 2023
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will meet with project staff to train them on the need for discharge summaries after a client discharges. A sign-in sheet will be available to show proof of meeting. This will occur by 3/4/24.
Project director will audit discharged charts on a monthly basis to ensure discharge summaries are present in the chart. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in four out of four discharged records reviewed.
Client #5 was admitted on June 30, 2023 and was discharged on July 3, 2023.
Client #7 was admitted on June 29, 2023 and was discharged on September 27, 2023.
Client #9 was admitted on August 30, 2023 and was discharged on September 28, 2023
Client #10 was admitted on July 19, 2023 and was discharged on July 24, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project director will update the policies and procedures to include documentation regarding follow-up timeframes. This will occur by 3/4/24.
Project director will meet with project staff to discuss importance of follow-up contact after discharge. This will also occur by 3/4/24.
Project director will audit discharged charts on a monthly basis to ensure compliance. |
709.54(a)(1) LICENSURE Purchasing food/equipment
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(1) Purchasing of food and equipment.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include purchasing of food and equipment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for dietetic services which include purchasing of food and equipment. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include receiving, storing and preserving of food stuff.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for dietetic services which include receiving, storing and preserving of food stuff. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance |
709.54(a)(3) LICENSURE Proper preparation of food
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(3) Proper preparation of food.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include proper preparation of food.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for dietetic services which include proper preparation of food. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(a)(4) LICENSURE Safety/sanitation
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(4) Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for dietetic services which include safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(a)(5) LICENSURE Personal hygiene
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(5) Personal hygiene for those in food preparation areas.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include personal hygiene for those in food preparation areas.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for dietetic services, including personal hygiene for those in food preparation areas. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(a)(6) LICENSURE Special dietary needs
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(6) Special dietary needs.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include special dietary needs.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for dietetic services, which include special dietary needs. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(b) LICENSURE Aftercare policy
709.54. Project management services.
(b) The project shall develop a written client aftercare policy.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written client aftercare policy.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's aftercare policies. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written client follow-up policy.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's follow-up policies. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(d)(1) LICENSURE Outreach Identifying Persons
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(1) Identifying persons in need of project services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include identifying persons in need of project services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's outreach service to identify persons needing project services. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(d)(2) LICENSURE Alerting Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(2) Alerting persons and their families to the availability of project services.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include alerting persons and their families to the availability of project services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's outreach service, including alerting persons and their families to the availability of project services. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |
709.54(d)(3) LICENSURE Encouraging Persons - Outreach
709.54. Project management services.
(d) The project shall develop a written plan providing for outreach services which includes, but is not limited to:
(3) Encouraging persons to utilize the service delivery system.
|
Observations
Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include encouraging persons to utilize the service delivery system.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The project director will update the policy and procedure manual to include a written plan for the project's outreach service, include encouraging persons to utilize the service delivery system. This will be completed by 3/4/24.
The project director will monthly review the policy and procedure manual to ensure ongoing compliance. |