INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 19, 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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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
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.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
709.17(a)(3) Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for an informed and voluntary consent form from the client for the disclosure of information to include the purpose of the disclosure were submitted and approved by the Department for the December 21, 2020 and January 15, 2022 annual licensing inspections. Obtaining an informed and voluntary consent form from the client for the disclosure of information to include the purpose of the disclosure were again found to be a deficiency in the July 19, 2022 licensing inspection.
Plans of correction for documentation of follow-up information in accordance with the facility policy and procedure manual were submitted and approved by the Department for the December 21, 2020 and January 15, 2022 annual licensing inspections. Obtaining documentation of follow-up information in accordance with the facility policy and procedure manual were again found to be a deficiency in the July 19, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to lack of staff the director will review within 24 hours of admission new client consents to ensure the informed consents are completed as required by regulations until clinical supervisor can be hired to complete the audits. In addition the director will review all discharges within 30 days to ensure follow up is completed within 30 days until clinical supervisor is hired to complete the chart reviews. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on four 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 name of the person, agency or organization to whom the disclosure is being made.
Client # 2 was admitted on April 4, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 4, 2022 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 3 was admitted on May 16, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 16, 2022 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 4 was admitted on April 13, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 13, 2022 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 6 was admitted on March 7, 2022 and was discharged on May 3, 2022. An informed and voluntary consent from the client for the disclosure of information dated March 7, 2022 did not provide the name of the person, agency or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselor called clients 2, 3,4,6 to come into the office to complete the informed consents. The office manager will do daily chart audits to ensure they are fully completed and notify the counselor and director of any deviance from regulations. |
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 two 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 purpose of the disclosure.
Client # 3 was admitted on May 16, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 16, 2022 to a government agency and "other" entity not named did not include the purpose of the disclosure.
Client # 6 was admitted on March 7, 2022 and was discharged on May 3, 2022. An informed and voluntary consent from the client for the disclosure of information dated March 7, 2022 to a government agency and "other" entity not named did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 14, 2022 and December 21, 2020 annual licensing inspection.
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Plan of Correction
The counselor called clients 3,& 6 to come into the office to complete the informed consents. The office manager will do daily chart audits to ensure they are fully completed and notify the counselor and director of any deviance from regulations. |
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 three of seven client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 1, 2, and 4.
Client # 1 was admitted on February 22, 2022 and was still active at the time of the inspection. A treatment plan developed on March 15, 2022 and updated May 31, 2022 indicated individual sessions once weekly and groups once weekly. A review of progress notes and record of service indicate group sessions did not occur once weekly. No individual sessions were documented in the client record after May 31, 2022.
Client # 2 was admitted on April 4, 2022 and was still active at the time of the inspection. A treatment plan developed on May 3, 2022 and updated June 28, 2022 indicated individual sessions once weekly and groups once weekly. A review of progress notes and record of service indicate group sessions did not occur once weekly. No individual sessions were documented in the client record after June 28, 2022.
Client # 4 was admitted on April 13, 2022 and was still active at the time of the inspection. A treatment plan developed on May 4, 2022 indicated individual sessions once weekly and groups once weekly. A review of progress notes and record of service indicate group sessions did not occur once weekly. No individual sessions were documented in the client record after May 4, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 14, 2022 annual licensing inspection.
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Plan of Correction
The director removed the incorrect formatted treatment plan and provided the counselor with the corrected format. Treatment plan was updated with client #4 and resigned. the chart will be audited weekly until a clinical supervisor is hired and then the clinical supervisor will continue the process going forward |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a complete client record to include a complete record of service in client records # 1, 2, and 6.
Client # 1 was admitted on February 22, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on May 31 and May 17, 2022 however, there were not documentation of these sessions on the client record of service.
Client # 2 was admitted on April 4, 2022 and was still active at the time of the inspection. A review of progress notes indicates an individual session occurred on June 28, 2022 however, there was not documentation of this session on the client record of service.
Client # 6 was admitted on March 7, 2022 and was discharged on May 3, 2022. A review of progress notes indicates an individual session occurred on March 17, 2022 however, there was not documentation of this session on the client record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director retrained counselor assistant on "record of service" and had counselor assistant update the form with missing information. Office manager will review charts weekly to ensure compliance with record of service and report deviance to director for resolution until clinical supervisor is hired.
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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 four of seven client records reviewed, the facility failed to provide a complete client record to include progress notes in client records # 1, 2, 4, and 6.
Client # 1 was admitted on February 22, 2022 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on May 17, April 26, 11, 5, and March 29, 2022 however, there were no progress notes for those dates in the client record.
Client # 2 was admitted on April 4, 2022 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on April 4, 2022 however, there were no progress notes for that date in the client record.
Client # 4 was admitted on April 13, 2022 and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on April 27, 2022 however, there were no progress notes for that date in the client record.
Client # 6 was admitted on March 7, 2022 and was discharged on May 3, 2022. A review of the record of service indicates a group session occurred on April 19, April 5, and March 29 and an individual session on March 30, 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.
This is a repeat citation from the January 14, 2022 annual licensing inspection.
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Plan of Correction
The director met with counselor reviewed and retrain on progress note requirements. Director will complete weekly chart audits until clinical supervisor is hired and the clinical supervisor will be responsible for continuing the process going forward. |
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 three 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 # 5 was admitted on January 11, 2022 and discharged on March 23, 2022. There was no follow-up information documented in the client record.
Client # 6 was admitted on March 7, 2022 and discharged on May 3, 2022. There was no follow-up information documented in the client record.
Client # 7 was admitted on March 28, 2022 and discharged on April 4, 2022. 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 January 14, 2022 and December 21, 2020 annual licensing inspection.
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Plan of Correction
The director has taken ownership of all discharges reviews within 15 days of discharge to ensure compliance with follow up until clinical supervisor can be hired then the clinical supervisor will complete chart review weekly to ensure compliance. |