INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on 04/21/2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Nuestra Clinica Rehabilitacion was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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Observations
Based on the investigation conducted on 04/21/21, a physical plant inspection was conducted, and the facility failed to ensure privacy during individual counseling sessions.
It was confirmed while individual counseling is being conducted staff members enter and exit the office.
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Plan of Correction
To ensure that privacy is observed during individual sessions the executive director has opened the additional office to be used for sessions while the inside office space is restructured. this will ensure that the facility does not have a recurrence.
The program director will be responsible to ensure actions remain implemented.
The corrective action has be initiated immediately, and the inside space will additionally be completed by May 30, 2021.
Effective today the outside space is in use and open for session |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on client record reviews during the investigation conducted on 04/21/21, the services record provided documentation of therapeutic group, but no individual sessions. No documentation of progress notes were found in client #3 record.
Client #3 admitted on date 02/12/21 and discharge 03/06/21.
Findings were discussed with facility
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Plan of Correction
It will be the responsibility of the clinical supervisor/facility director to randomly audit charts weekly for 6 months, then biweekly for 6 months to ensure compliance with individual progress notes. Immediate retraining of all counselors to take place with clinical supervisor and facility director on April 26th to address proper documentation and regulations.
the chart as indiacte4d can not be corrected as it was a closed chart and we are not able to change closed charts. |