INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Asociacion De Puertorriquenos En Marcha Proyecto Nueva Vida 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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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on review of administrative documentation, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed on November 25, 2013. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2011 through 2012 fiscal year ended on June 30, 2012. However, the facility's financial audit for this period was not completed until January 10, 2013.
The findings were confirmed during an interview with the project director on November 25, 2013 at approximately 3:45 P.M.
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Plan of Correction
Every effort will be made in the future to complete the agency's audit within six months of FYE. The agency will choose the auditor and otherwise begin to lay the groundwork for the audit before the end of the fiscal year so the audit proper can begin on July 1, as soon as the books are closed. Priority shall be given within the Finance Department to the audit's timely completion, with the cooperation of the other departments.
APM's Sr. VP of Administration and Finance, is directly responsible for ensuring the audit is completed in good order while its CEO is ultimately responsible.
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to complete a personnel record that included documentation of results of reference investigations in one of four personnel records reviewed and a work performance evaluation at least annually in one of two personnel records reviewed.
The findings include:
On November 25, 2013, four personnel records requiring documentation of reference checks and two personnel records requiring documentation of performance evaluations at least annually were reviewed. The facility failed to complete a personnel record that included documentation of an annual work performance evaluation, specifically, personnel record # 1. Also, the facility failed to complete a personnel record that included documentation of results of reference investigations in one of four personnel records reviewed, specifically, personnel record # 5.
Employee # 1, the project director, was hired March 14, 2005. Employee # 1 was due an annual work performance evaluation by March 13, 2013. However, as of November 25, 2013, the most recent work performance evaluation in personnel record # 1 was March 13, 2012.
Employee # 5, a receptionist, was hired April 1, 2013. However, personnel record # 5 did not include documentation of reference checks as of November 25, 2013.
The findings were confirmed during an interview with the facility director, counselor, counselor assistant, and quality assurance staff on November 25, 2013 at 3:45 P.M.
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Plan of Correction
It is agency policy to contact every new hire's references prior to their employment. APM's HR Director has been reminded of this policy and will faithfully implement it. Employee #5 has brought in her or his references. They have been checked by HR and the appropriate documentation has been placed in her personnel file.
It is agency policy to do annual performance reviews of all staff by the end of the fiscal year, except for employee #1. Employee #1's review, as CEO, is due by February 1. This has been communicated to Employee #1's supervisor. Employee #1's performance review will be completed by APM's Board Chair or his (in this case) representative by February 1, 2014.
In the future, all employee performance reviews will be completed by their direct supervisors by the end of the fiscal year on June 30, with the exception of employee #1. Employee #1's review, as CEO, will be completed by February 1 by the board chair or his or her representative following completion of the corporate audit, due December 31. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in five of nine client records reviewed.
The findings include:
On November 25, 2013, nine client records requiring documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan were reviewed. The facility did not document the type and/or frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in five of nine client records reviewed, specifically, client records # 1, 2, 6, 7, and 8.
Client # 1 was admitted July 10, 2013. The individual treatment and rehabilitation plan was completed July 24, 2013. However, the individual treatment and rehabilitation plan did not include documentation of the type and frequency of treatment and rehabilitation services as of November 25, 2013.
Client # 2 was admitted July 15, 2013. The individual treatment and rehabilitation plan was completed July 15, 2013. However, the individual treatment and rehabilitation plan did not include documentation of the type and frequency of treatment and rehabilitation services as of November 25, 2013.
Client # 6 was admitted September 9, 2013. The individual treatment and rehabilitation plan was completed September 9, 2013. However, the individual treatment and rehabilitation plan did not include documentation of the type and frequency of treatment and rehabilitation services as of November 25, 2013.
Client # 7 was admitted August 21, 2013. The individual treatment and rehabilitation plan was completed August 21, 2013. However, the individual treatment and rehabilitation plan did not include documentation of the type and frequency of treatment and rehabilitation services as of November 25, 2013.
Client # 8 was admitted September 19, 2013. The individual treatment and rehabilitation plan was completed September 19, 2013. However, the individual treatment and rehabilitation plan did not include documentation of the type and frequency of treatment and rehabilitation services as of November 25, 2013.
The findings were confirmed during an interview with the facility director, counselor, counselor assistant, and quality assurance staff on November 25, 2013 at 4:00 P.M.
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Plan of Correction
The treatment plans for client records # 1, 2, 6, 7, and 8 have been revised to include both type and/or frequency. APM's Quality Assurance Coordinator for health services will review treatment plans on a weekly basis to ensure compliance.
Further, APM approved a change in the forms used that makes the need to record both type and frequency in the treatment or rehabilitation plan more obvious to the provider. In short, both type and frequency of services to be provided are now individually required answers in the form. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in seven of nine client records reviewed.
The findings include:
On November 25, 2013, nine client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in seven of nine records reviewed, specifically, client records # 2, 3, 5, 6, 7, 8, and 10.
Client # 2 was admitted July 10, 2013. The individual treatment and rehabilitation plan was completed on July 15, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 25, 2013.
Client # 3 was admitted February 28, 2013. The individual treatment and rehabilitation plan was completed on March 6, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 25, 2013.
Client # 5 was admitted February 21, 2013. The individual treatment and rehabilitation plan was completed on February 21, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 25, 2013.
Client # 6 was admitted September 9, 2013. The individual treatment and rehabilitation plan was completed on September 9, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 25, 2013.
Client # 7 was admitted August 21, 2013. The individual treatment and rehabilitation plan was completed on August 21, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 25, 2013.
Client # 8 was admitted September 19, 2013. The individual treatment and rehabilitation plan was completed on September 19, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 25, 2013.
Client # 10 was admitted February 13, 2013 and discharged September 11, 2013. The individual treatment and rehabilitation plan was completed on February 13, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 25, 2013.
The findings were confirmed during an interview with the facility director, counselor, counselor assistant, and quality assurance staff on November 25, 2013 at 4:00 P.M.
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Plan of Correction
The treatment plans for clients # 2, 3, 5, 6, 7, 8, and 10 will be revised by 12/31/13 to include documentation of support services. The treatment plan for client #10 cannot be changed because the client has been discharged.
Further, changes were made to the Treatment / Rehabilitation Plan forms to add an array of Supportive Services (e.g. Case Management, 12 step group) to which consumers will be directed. This change serves as a "tickler" for the provider to discuss these services with every consumer.
Finally, treatment plans will be reviewed on a bi-weekly basis by APM's Quality Assurance Coordinator to ensure compliance with the listing of support services, as a part of our overall compliance program. |