INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 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 of SACA Drug and Alcohol Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure the clinical supervisor participate in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position.
Employee #2 was employed as a clinical supervisor on May 11, 2024 and was still in the position at the time of the inspection. Only the month of June had documented supervision.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The SUD Program Director will begin monthly supervision with the assigned clinical supervisor. Supervision will be documented on a monthly basis as it occurs and placed in staff personnel record. One week prior to the end of the month SUD Program Director will review monthly check off list to ensure all required supervisions have occurred and have been documented. Process implemented as of October 2024. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies within seven days of hire.
Employee #1 was hired on September 3, 2024 as the Project Director/Facility Director and was still in the position as of the date of the inspection. The training was completed on September 16, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The SUD Program Director will ensure all new hires complete on day 2 of employment the individual training plan, which includes the Emergency/Safety plan. The SUD Program Director, will ensure the required training is completed within the first 7 days of employment. Monthly personnel chart checks will then be completed for any pending trainings that need completed. In the instance that the new hire is the Program Director, the Quality Assurance Director will ensure that all required trainings are completed with in the mandated time frames. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the December, 2023 through September, 2024 fire drill logs during the inspection, the facility failed to document the exit used on September 24, 2024 and did not document problems encountered on all fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill forms have been updated to include: the exit used as well as the problems encountered. There has also been a bold statement added to the form stating all areas of the form must be completed. The SUD Director will review the form immediately after the drill for inspection of completion in its entirety. Effective October 2024. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the December, 2023 through September, 2024 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill during the months of January, March, June, July and August.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill forms have been updated to include: If the fire alarm was set off during the time of the drill. Staff responsible for the fire drills has been fully trained on the procedure for running the fire drills and the complete documentation process. There has also been a bold statement added to the form stating all areas of the form must be completed. The SUD Director will review the form immediately after the drill for inspection of completion in its entirety. Effective October 2024. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of six applicable records reviewed.
Client #1 was admitted on July 23, 2024 and was still active at the time of the inspection. The treatment plan dated August 26, 2024 indicated one hour of individual therapy weekly. There was no documentation of the client receiving individual therapy since September 9, 2024.
Client #2 was admitted on February 23, 2024 and was still active at the time of the inspection. The treatment plan dated March 9, 2024 indicated weekly individual sessions. There was no documentation that the client received individual sessions between July 9, 2024-August 6, 2024; August 6, 2024- August 20, 2024; August 20, 2024-September 3, 2024 and September 3, 2024-Ocotber 8, 2024.
Client #5 was admitted on April 9, 2024 and was discharged on August 22, 2024. The treatment plan dated January May 2, 2024 indicated weekly individual sessions. There was no documentation that the client received individual therapy between May 2, 2024-July 2, 2024 and July 24-August, 22, 202.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Counselor will ensure client is scheduled for sessions aligned with the treatment plan expectations. The front office staff will make appointment reminder calls to the clients and document these calls have been completed. If the client does not show for the scheduled weekly appointment, the counselor will document in a progress note the no show and attempt calling the client to rescheduled. The counselor will present these clients during weekly case review for guidance and decision in client case. Effective October 2024. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed at the time of treatment planning.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
SUD Program Director will conduct weekly case review meetings. During case review meeting the counselor will present the client case consult document for review and recommendations for client treatment and or any progress or lack of in treatment. Documentation will then be file in client record. Effective October 2024. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in four out of four applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed at seven and 15 days following discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When a client is discharged the counselor will prepare the seven and fifteen day follow up letters. The front office staff will then send out these letter in the designated time frame (7 and 15 days). The front office will also make a phone call to attempt contact via phone as well. The front office will then document the phone call and phone call results in the clients chart. Effective October 2024. |