INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on December 20, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on December 20, 2016 at approximately 10:30 A.M., it was discovered that the facility failed to ensure that the the grounds were maintained in good repair at all times. There was exposed wiring under the table in the conference room and an exposed electrical outlet box hanging from the ceiling in a group/confernece area used by staff and clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance met with Vice President of Health Services to discuss physical plant deficiencies found during inspection. A report was submitted to Facilities Management for review to address the exposed wiring under the table in the conference room and the exposed electrical outlet box hanging from the ceiling immediately. Quality Assurance will conduct on-going monthly audits of the physical plant, including the wiring under the table in the conference room and electrical outlet in the group/conference room and report any safety hazards to Facilities Management. Quality Assurance will submit quarterly reports of the physical plant audits to Vice President and update Quality Improvement Plan as needed.(QIP) |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the November 2015 through November 2016 fire drill logs was conducted during the onsite inspection. Each log, except for the month of April 2016, failed to include the exit route used during the fire drill. The logs for the months of April, July, and October 2016 failed to include the amount of time it took for the evacuation. Additionally, the log for the month of October 2016 failed to include the time the drill took place.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance reviewed and corrected each log to include the exit route during the fire drill. QA reviewed and completed the logs for the months of April, July, and October 2016 to include the amount of time it took for the evacuation. QA reviewed and corrected the log for the month of October 2016 to include the time the drill took place. At the end of each monthly fire drill, QA will review and ensure completeness of all fire drill logs,for accuracy, before filing. Effective immediately. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # ' s 1, 3, 4, 6, 7, and 8. Additionally, the facility disclosed information prior to the patient signing an informed and voluntary consent to release form in client record # 8. Consent to release information forms in client record # ' s 2, 4, 5, 6, 7, and 8 were missing required information.
Client #1 was admitted on 7/20/16 and was discharged on 10/20/16. The record contained a consent to release information form to probation/parole, signed and dated on 7/20/16, which allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the psychosocial evaluation, psychiatric evaluation, update treatment plan status, and discharge summary.
Client #2 was admitted on 8/2/16 and was an active client at the time of inspection. The record contained a consent to release information form signed and dated on 8/2/16 to the client ' s address, which did not include the information to be released or the purpose of the disclosure.
Client #3 was admitted on 7/15/16 and was an active client at the time of the inspection. The record contained documentation of a facsimile containing UDS results to the funding source, which exceeds the limits established by 4 Pa. Code 255.5.
Client #4 was admitted on 10/14/16 and was an active client at the time of the inspection. The record contained a consent to release information form to probation/parole, signed and dated on 10/14/16, which did not specify the purpose of disclosure and allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the discharge summary.
Client #5 was admitted on 2/8/16 and discharged on 6/2/16. The record contained a consent to release information form signed and dated on 2/8/16 to another treatment provider, which did not include the information to be released or the purpose of the disclosure. Another consent to release information form signed and dated on 2/8/91 by both staff and client, did not have a purpose of disclosure or recipient of information being released.
Client # 6 was admitted on 6/23/16 and was discharged on 10/31/16. The record contained documentation of correspondence with a government agency, dated on 10/31/16, releasing UDS results and medication information, which exceeds the limits established by 4 Pa. Code 255.5. The consent form to the government agency did not contain a purpose for the disclosure and allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the psychosocial evaluation, psychiatric evaluation, update treatment plan status, and discharge summary.
Client #7 was admitted on 3/4/16 and was discharged on 6/21/16. The record contained a consent to release information form to a government agency, signed and dated on 3/4/16, which allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the medication information, psychosocial evaluation, psychiatric evaluation, and update treatment plan status. The record also contained a consent to release information form to probation/parole, signed and dated on 3/4/16, that was missing an expiration date and allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the UDS results, medication information, psychosocial evaluation, psychiatric evaluation, discharge summary, and update treatment plan status.
Client #8 was admitted on 3/16/16 and was discharged on 7/29/16. The record contained a consent to release information form to probation/parole, signed and dated on 3/16/16, that was missing the purpose of disclosure and allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the medication information, psychosocial evaluation, psychiatric evaluation, discharge summary, and update treatment plan status. The record also contained a consent to release information form to the client ' s primary care physician, signed and dated on 3/16/16, which did not include a purpose for the disclosure of information. Additionally, the record contained a consent to release information form signed and dated on 3/16/16, which failed to include a recipient of information, information to be disclosed, or purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Vice President and Quality Assurance facilitated a meeting with all Clinical staff to review the results of the inspection on 12/29/16. The consent forms in client record #'s 2 and 4, have been given to the Therapists to correct with the clients. Client records #'s 1 and 8 will be given to Therapist to review for and be educated on what information should not be included when releasing information to probation/parole and how to complete consent forms when releasing/obtaining information to or from primary care physicians. Compliance with fully completing required information in consent forms will be reinforced in scheduled supervision and quality assurance in-services. Client record #'s 2 and 4, were reviewed and will be given to Therapists to correct the required missing information with the clients. Client #3 will be reviewed with the Therapist and QA will provide education on what information should not be released to the funding source and what information exceeds the limits established by 4 Pa. Code 255.5. The consent forms will be modified and updated by QA to include only the five categories of specific information which can be released as well as, if client accepted or refused a copy of consent form. Targeted in service trainings on these deficiencies and other areas will be facilitated through-out the year, and reinforced during supervision. There will be on-going monitoring from QA to ensure completeness and accuracy of consent forms during monthly audits. QA will submit quarterly reports to Vice President with Quality Improvement Plan and update as needed. Person(s) responsible, Quality Assurance Coordinator, Clinical Supervisor, Vice President of Health Services |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
During the onsite inspection on December 20, 2016, a review of client records was conducted. During the review, it was discovered that the facility failed to ensure that client records were readily accessible for at least four years after discharge as records for three clients discharged within the last year could not be located by facility staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance and Vice President of Services reviewed current chart tracking process. QA worked with the receptionists to locate the three discharge charts that were missing.
QA implemented a new chart tracking process for discharged clients. All charts will be placed in designated area once it has been closed. QA will monitor this process on-going and keep list of discharged clients in the tracking system to ensure that their charts are placed in the designated area and readily accessible. There were also modifications to the chart tracking process including the signing out of charts by staff from the chart room. QA implemented new chart sign out sheets for all staff to use effective immediately. Person(s) responsible, Quality Assurance |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a review of the facility's data collection system, the facility failed to ensure that the system utilized provided the client admission and discharge dates within the specified time period of November 2015 to December 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance and Vice President of Services reviewed current client admission process. There were modifications to the client admission process including the implementation of a data collection system to track client admission and discharge dates from the program. QA will obtain information from intake process to track those clients who have completed the entire intake process before being admitted into the program, and update the data collection system. QA will obtain lists of discharged clients from Therapists and update the data collection system. There will be on-going monitoring by QA to ensure accuracy and the most up-to-date information. Person(s) responsible, Quality Assurance |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
On December 20, 2016, the facility's Unusual Incident Reporting policy was reviewed and it was discovered that the facility failed to include four of five unusual incident response procedures. The four procedures not included are 1) prompt review and identification of the causes for the unusual incident, 2) implementation of a timely and appropriate corrective action plan, when applicable, 3) ongoing monitoring of the corrective action plan, and 4) reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with applicable confidentiality laws.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Vice President of Health Services and Quality Assurance reviewed the Unusual Incident Reporting Policy following the day of the inspection. QA will modify the policy to include the four missing procedures: 1) prompt review and identification of the causes for the unusual incident, 2) implementation of a timely and appropriate corrective action plan, when applicable, 3) ongoing monitoring of the corrective action plan, and 4) reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with applicable confidentiality laws. In addition to the modifications, there will be on-going monitoring of the policy to ensure appropriate implementation by staff and updated on an as needed basis. Person(s) responsible, Quality Assurance and Vice President
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of client records, the facility failed to maintain onsite a photograph of clients, which includes the patient's name and birthday, for client # 2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance reviewed client #2 chart, and reminded intake staff of all required documentation to fully complete the intake process. Therapist will obtain a copy of the client's photo identification during next appointment. There will be on-going monitoring of the intake process to ensure all required documentation is collected from the client as part of the monthly QA chart review. Person(s) responsible, Quality Assurance, Therapist |
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 a review of client records, records for client # ' s 1, 3, 7, and 8 had treatment plan updates completed after the regulatory timeframe or were missing at the time of the inspection.
Client #1 was admitted on 7/20/16 and was discharged on 10/20/16. The comprehensive treatment and rehabilitation plan was completed on July 20, 2016 and no treatment plan updates were completed prior to discharge.
Client #3 was admitted on 7/15/16 and was an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on July 15, 2016 and the treatment plan update was due no later than September 15, 2016; however, the update was not completed until November 9, 2016.
Client #7 was admitted on 3/4/16 and was discharged on 6/21/16. The comprehensive treatment and rehabilitation plan was completed on March 4, 2016 and no treatment plan updates were completed prior to discharge.
Client #8 was admitted on 3/16/16 and was discharged on 7/29/16. The comprehensive treatment and rehabilitation plan was completed on March 16, 2016 and no treatment plan updates were completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Vice President and Quality Assurance facilitated a meeting with all Clinical staff to review the results of the inspection on 12/29/16 to provide updates to the monitoring process. After review of Client chart #1, 3, 7, 8, QA identified that the clinical staff could benefit from targeted in service trainings on these deficiencies of incomplete documentation and other areas, which will be facilitated through-out the year, and reinforced during supervision. There will be on-going monitoring by QA to ensure that the documentation appropriately reflects updates within regulatory timeframes and is present prior to discharge. Person(s) responsible, Quality Assurance and Clinical Supervisor |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record in client records # ' s 1, 5, 6, 7, and 8.
Client #1 was admitted on 7/20/16 and was discharged on 10/20/16. The client record did not contain any documentation of case consultation, follow-up information, record of services as of the date of the inspection.
Client #5 was admitted on 2/8/16 and discharged on 6/2/16. The client record did not contain any documentation of case consultation or follow-up information as of the date of the inspection.
Client # 6 was admitted on 6/23/16 and was discharged on 10/31/16. The client record did not contain any documentation of case consultation, follow-up information, or discharge summary as of the date of the inspection.
Client #7 was admitted on 3/4/16 and was discharged on 6/21/16. The client record did not contain any documentation of case consultation as of the date of the inspection.
Client #8 was admitted on 3/16/16 and was discharged on 7/29/16. The client record did not contain any documentation of case consultation as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Vice President of Health Services and Quality Assurance facilitated a meeting with all Clinical staff to review the results of the inspection on 12/29/16 to provide updates to the quality improvement and monitoring process. After review of client charts #1, 5, 6, 7, 8, QA identified that clinical staff could benefit from targeted in service training on these deficiencies of incomplete documentation and other areas, which will be facilitated through-out the year, and reinforced during supervision. QA will give charts #'s 1, 5, 6 to Therapists to enter missing records of services, to conduct follow-up for discharged clients, document attempts, and complete missing discharge summaries.
There will be on-going monitoring by QA to ensure that the documentation appropriately reflects updates throughout service delivery. QA will monitor discharge planning and continuing care support process to ensure documentation of follow-up with clients within 30 days after discharge date. QA will conduct on-going monthly audits to ensure compliance with the discharge planning process and that follow-up is being done by Therapist. Person(s) responsible, Quality Assurance and Clinical Supervisor
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