INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2022 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of employee records, the facility failed to provide documentation of a qualifying degree for a counselor position from an accredited college or university in two of two counselor employee records.
Employee # 2 was hired as a counselor on October 4, 2021 and was still in this position at the time of the inspection. A review of employee #2's personnel record indicates a degree that was not received from an accredited college or university.
Employee # 3 was hired as a counselor on October 26, 2021 and was still in this position at the time of the inspection. A review of employee #3's personnel record indicates a degree that was not received from an accredited college or university.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee 2 was changed to another facility and given the position of counselor assistant whereby credentialing has been met and employee will have supervision until the acquisition of certification.
In the future the newly hired HR manager will be responsible to request transcript and diploma for verification through middle states accreditation for all clinical new hires. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of SRFSR Staffing Requirement Facility Staffing Form and counselor qualifications, the facility failed to comply with the client/counselor ratio of 35/1 in an outpatient facility.
Two of two counselors do not qualify for the counselor position and are ineligible to be included in the caseload calculation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee 2 & 3 are under review through DDAP for exceptions. The director has changed employee #3 to a counselor assistant and will supervise employee based on 704 staffing regulations for a counselor assistant.
employer #2 will be supervised under counselor assistant regulations until his application for the CAAC credential is completed.
Employees will be under direct supervisor of a fully credentialed counselor or higher until full credentialing is obtained.
all degrees and transcripts will be verified through the HR dept. and Dept. of Education and Middle States credentialing from this point forward. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 2 was admitted on December 6, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 6, 2021 to county agency did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 21, 2020 annual licensing inspection.
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Plan of Correction
Client #2 chart was pulled and the client came in to the office to complete the consent correctly.
The case manager will do random weekly chart audits for compliance for the next 6 months.
The director will do monthly random chart audits.
Director went over and gave directions on completion of informed consent to clinical team. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on three of seven client records reviewed, the facility failed to document a completed informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 1 was admitted on October 5, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated October 5, 2021 to a "friend" did not provide the purpose of the disclosure.
Client # 2 was admitted on December 6, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 6, 2021 to an emergency contact did not provide the purpose of the disclosure.
Client # 4 was admitted on October 29. 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated October 29, 2021 to two county agencies did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 21, 2020 annual licensing inspection.
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Plan of Correction
All chart in question were pulled and the clients came in to the office to complete the consent correctly.
The case manager will do random weekly chart audits for compliance for the next 6 months.
The director will do monthly random chart audits.
Director went over and gave directions on completion of informed consent to clinical team
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709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.
Client # 2 was admitted on December 6, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to an attorney did not have the date of signature for the consent.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 21, 2020 annual licensing inspection.
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Plan of Correction
Clients chart was pulled and the client came in to the office to complete the consent correctly.
The case manager will do random weekly chart audits for compliance for the next 6 months.
The director will do monthly random chart audits.
Director went over and gave directions on completion of informed consent to clinical team
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709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the dated signature of witness.
Client # 2 was admitted on December 6, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to an attorney did not have the dated signature of the witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients chart was pulled and the client came in to the office to complete the consent correctly.
The consent was then singed by a witness correctly
The case manager will do random weekly chart audits for compliance for the next 6 months.
The director will do monthly random chart audits.
Director went over and gave directions on completion of informed consent to clinical team
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709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the date, event or condition upon which the consent will expire.
Client # 2 was admitted on December 6, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 22, 2021 to an attorney did not provide the date, event or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 21, 2020 annual licensing inspection.
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Plan of Correction
Clients chart was pulled and the client came in to the office to complete the consent correctly.
The consent was then completed fully and signed by client
The case manager will do random weekly chart audits for compliance for the next 6 months.
The director will do monthly random chart audits.
Director went over and gave directions on completion of informed consent to clinical team
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days in client record # 3.
Client # 3 was admitted on October 27, 2021 and was still active at the time of the inspection. A treatment plan was developed on November 3, 2021. The treatment plan update was due to occur on January 3, 2022 however, there was no treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client was called into the office to meet with counselor. Treatment plan was discussed and updated.
Client #2 chart was pulled and the client came in to the office to complete the consent correctly.
The case manager will do random weekly chart audits for compliance for the next 6 months.
The director will do monthly random chart audits.
counselor will also be sent to training on treatment plans
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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 four of seven client records reviewed, the facility failed to assure counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 2, 3 and 4.
Client # 1 was admitted on October 5, 2021 and was still active at the time of the inspection. A treatment plan developed on October 19, 2021 indicated one individual and one group weekly. A review of progress notes and record of service indicate group sessions and individual sessions did not occur.
Client # 2 was admitted on December 6, 2021 and was still active at the time of the inspection. A treatment plan developed on December 6, 2021 indicated one individual and one group weekly. A review of progress notes and record of service indicate group sessions did not occur and there were no individual sessions documented for the weeks of December 6-10, 2021, December 26, 2021-January 1, 2022, and January 2-8, 2022.
Client # 3 was admitted on October 27, 2021 and was still active at the time of the inspection. A treatment plan developed on November 3, 2021 indicated one individual and one group weekly. A review of progress notes and record of service indicate only one group session on January 5, 2022.
Client # 4 was admitted on October 29, 2021 and was still active at the time of the inspection. A treatment plan developed on November 10, 2021 and updated January 6, 2022 indicating one individual and one group weekly. A review of progress notes and record of service indicate group sessions did not occur.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director retrained clinical team on the process of documenting the agreed upon treatment plan and the corresponding notes.
All staff was informed of the need to use the record of service and complete notes on the date of service.
Active clients were asked to return to update treatment plans and adjust activities that will take place to ensure compliance on both sides.
Case Manager will audit charts weekly for 6 months and the director will audit monthly |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a complete client record to include progress notes that are reflective of the clients record of service in client records # 1, 3, and 4.
Client # 1 was admitted on October 5, 2021 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on October 19 and November 1, 2021 however, there were no progress notes for those dates in the client record.
Client # 3 was admitted on October 27, 2021 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on October 27, December 6, and December 13, 2021 however, there were no progress notes for those dates in the client record.
Client # 4 was admitted on October 29, 2021 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on November 17, 2021 and January 12, 2022 however, there were no progress notes for those dates in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director retrained clinical team on the process of documenting the agreed upon treatment plan and the corresponding notes.
All staff was informed of the need to use the record of service and complete notes on the date of service.
Active clients were asked to return to update treatment plans and adjust activities that will take place to ensure compliance on both sides.
Progress notes will be printed and a copy given to the director for review daily.
Case Manager will audit charts weekly for 6 months and the director will audit monthly
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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 one of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 30 days by letter.
Client # 6 was admitted on June 15, 2021 and discharged on July 13, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 21, 2020 annual licensing inspection.
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Plan of Correction
Director met with clinical staff to retrain on the process of follow-up and aftercare compliance.
Letters were sent to the clients that had already been discharged to follow up with them.
The case manager will audit charts weekly for 6 months and the director will audit monthly
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