INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on September 4, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Nuestra Clinica of SACA Drug and Alcohol was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
|
Observations
Based on a physical plant inspection, the Facility Environment policy and the Confidentiality policy, the facility failed to secure hard copy client records within locked storage containers.
According to the Facility Environment policy, the Program Manager and Frond Desk Scheduler are responsible for ensuring the doors to the filing cabinets are locked at all times.
Per the Confidentiality policy, individual files are records are to be kept locked in filing/storage cabinets.
Three Bankers Box's, containing client records, were observed on the floor of the file room. Additionally, there were three file cabinets that contained client records and the cabinets were unlocked and some of the drawers were partially open. It was reported by facility staff that the cabinet locks do not work.
|
Plan of Correction
On 9/5/2024 client files were transferred to file cabinet with functioning locking mechanism, which are also located behind locked doors. Office staff were re-educated on the importance of ensuring client files are locked and secured at all times. Program Director and front desk scheduler will ensure the filing cabinet is locked at all times. Program Director will make random, unannounced office checks to ensure cabinets are locked at all times several times a week. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
|
Observations
Based on a physical plant inspection conducted on September 4, 2024, the facility failed to restrict drug and alcohol treatment services within the premises designated by their drug and alcohol license.
During the physical plant inspection, it was observed that counselor offices, where drug and alcohol treatment services are provided, are located outside of the designated area for those services. Additionally, the offices were located outside the posted floor plan.
|
Plan of Correction
On 9/16/24 floor plans were updated to reflect appropriate designated NC Outpatient areas. Counselor offices have been moved back to original licensed areas. Floor plan has been labeled to reflect exact locations and evacuation routes. Program Director will ensure floor plan does not change and correct floor plans are posted at all times. |