INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted June 4, 2024 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:
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Plan of Correction
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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.
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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 one of three employee records reviewed.
Employee #1 was hired on May 11, 2024 as the facility director and was still in the position as of the date of the inspection. There was no training plan documented.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
The Training Plan will be developed within the first seven days of employment and annually at the commencement of each calendar year.
The Director of Quality, Control, and Compliance will conduct random staff file audits to ensure that the project director adheres with compliance regulations. Additionally, the project director will audit staff files every three months as of 07/01/2024
Facility Director record reviewed, individual training plan has been created. Completed 06/14/2024.
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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 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 intake coordinator on April 5, 2022 and was due to have the communicable disease trainings no later than April 5, 2024. There was no documentation in the personnel file of the completion of the HIV/AIDS training and TB/STD training until May 23, 2024.
Employee #5 was hired as a house manager on December 23, 2017 and was due to have the communicable disease trainings no later than December 23, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and TB/STD training at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
The project director will review all staff files for completion of Mandatory Communicable Disease Training by 07/09/2024. Any mandatory trainings that have not been completed will be included in the training plan for the current year. Staff members will be given a period of 15-30 days to complete any mandatory missed trainings.
The Director of Quality, Control, and Compliance will conduct random staff file audits to ensure that the project director adheres with compliance regulations. Additionally, the project director will audit staff files every three months as of 07/09/2024 to ensure continued compliance of reg 704.11 (c)(1).
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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 facility schedule for the week of May 27th- June 2nd. T he facility failed to ensure at least on person trained in CPR skills was onsite during the project ' s hours of operations.
The facility failed had no CPR coverage for the following shifts:
May 27, 2024 from 11pm-7am
May 28, 2024 from 4pm-7am
May 29, 2024 from 11pm-7am
May 30, 2024 from 11pm-7am
June 2, 2024 from 11pm-7 am
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
The project director will audit staff files by or before 06/14/2024 to verify the validity of CPR training.
The project director will conduct a weekly assessment of the staff work schedule, one week in advance, to ensure that there is always at least one person trained in CPR during each shift, commencing from 06/14/2024.
The project director will ensure that all staff members are trained in CPR by 06/30/2024 to prevent any lapses in CPR coverage and to comply with regulation 704.11 (c)(2).
Six months prior to the expiration of CPR certification, the project director will include CPR into the individual training plan of each staff member, allowing staff sufficient time to renew their certification. In order to guarantee that the Project Director is in compliance, the Director of Quality Control and conformance will conduct random staff file audits.
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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.
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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 in the use of the fire extinguishers upon employment.
Employee #1 was hired May 11, 2024 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 #2 was hired on January 1, 2024 for the position of counselor and was still employed at the time of the inspection. A training was not documented in the employee record until May 14, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 6, 2023 licensing inspection.
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Plan of Correction
Fire Extinguisher training will be completed with 7 days of hire.
The Project Director will develop a staff record check-list that will be included in the staff records of all employees. This checklist will include Fire Extinguisher Training and all other required DDAP trainings to ensure compliance.
Review of Fire Extinguisher Training will be conducted annually.
The Director of Quality, Control & Compliance will conduct a random audit of staff records to guarantee compliance.
Employee 1 & 2 have completed Fire Extinguisher training.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of 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 May 11, 2024 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 #2 was hired on January 1, 2024 for the position of counselor and was still employed at the time of the inspection. A training was not documented in the employee record until May 14, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 6, 2023 licensing inspection.
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Plan of Correction
Emergency training plan will be completed and reviewed within 7 days of hire to ensure compliance of reg 705.10. (d)(3).
The Project Director will develop a staff record check-list that will be included in the staff records of all employees. This checklist will include Emergency Plan Training and all other required DDAP trainings to ensure compliance.
The Director of Quality, Control & Compliance will conduct a random audit of staff records to guarantee compliance.
Employee 1 & 2 will complete training on or before 07/03/2024.
Emergency Plan Training has been completed. |
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.
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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.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
The Director of Quality, Control, and Compliance and the Project Director will ensure that the P&P manual is reviewed annually and that regulation 709.23 is adhered to. The CEO will re-sign the manual annually following a review or any amendments that occur prior to the annual review.
The onsite draft manual has been replaced with an updated policy and procedure manual that includes signature as of 06/05/2024. |
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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in nine out of nine 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.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
Prior to disclosing private client-identifying information, the staff will verify that consent has been obtained and that the information may be released. All staff responsible for disseminating client information must review the Privacy and Confidentiality section of the P&P manual, sign confidentiality agreement and take confidentiality training on or before 07/30/2024.
The project director will conduct random audits of client charts to ensure staff compliance reg 709.28.
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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.
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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.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
The Director of Quality, Control, and Compliance and the Project Director will collaborate with Nurse to ensure that the manual include all Medication control required policies and procedures according to reg 709.32.
P&P manual will be reviewed annually by Director of Quality Control & Compliance any updates will require approval and signature of the CEO.
Completed: The manual has been updated to include written policies and procedures concerning regulation 709.32(c)(5) as of 06/05/2024.
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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.
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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 two of five applicable records reviewed.
Client #5 was admitted on April 30,2024 and was discharged on May 2, 2024.
Client #6 was admitted on February 27, 2024 and was discharged on March 9, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
A Discharge Summary shall be completed for all clients within 7 days of their discharge. The Facility Director will review and sign the Discharge Summary within the same period.
The project director will conduct random chart audits of discharged records and will arrange meetings with project staff to review findings and address any deficiencies found on or before 07/15/2024.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up information in two out of five applicable records reviewed.
Client #5 was admitted on April 30,2024 and was discharged on May 2, 2024.
Client #6 was admitted on February 27, 2024 and was discharged on March 9, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 6, 2023 licensing inspection
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Plan of Correction
The outreach staff and or assigned counselor will conduct a 7- and 30-day follow-up with the client who has successfully completed the program. The Policy and Procedure manual has been revised to include this update on 06/05/2024.
The project director will conduct an audit of discharged charts and hold meetings with project staff to emphasize the significance of follow-up communication following discharge. This will occur on or before 07/15/2024.
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