INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Asociacion Puertorriquenos en March Inc. 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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709.28 (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 a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of eight client records reviewed.
Client #1 was admitted on July 24, 2024 and was active at the time of the inspection. A release of information form to a court was signed and dated by the client on July 24, 2024; however, there was no specific name of the person, agency, or organization to whom the disclosure was to be made to documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The release of information to a court was signed and dated by the client on July 24, 2024; without the specific name of the person, agency, or organization to whom the disclosure was to be made will be voided.
Front desk staff at this clinic will contact client #1 and provide a new release form to complete with the specific name of the person, agency, or organization to whom the disclosure is to be made before 01/10/2025. The program director will ensure this task is completed.
Program Director/ DA supervisor will provide supervision to all Substance abuse counselors on the need to complete this form with all the details including the name, person or organization to who the information will be released. |
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 a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of eight client records reviewed.
Client #1 was admitted on July 24, 2024 and was active at the time of the inspection. A release of information form to an emergency contact was signed and dated by the client on July 24, 2024; however, there was no specific information to be disclosed documented on the release form.
This is a repeat citation from the January 3, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 chart, the release of information to an emergency contact without the specific information to be disclosed will be voided. The front desk at this clinic will call the client and inform them about the new release form to be completed for emergency contact with the specific information to be disclosed. Staff will invite client #1 to the clinic to sign this form by 01/10/2025. The program director provided the new form the front desk staff. Program director will ensure this new form is added to the DA Intake packet to ensure all new clients will sign this from. Program Director will ensure this task is completed. |
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 a review of client records, the facility failed to document the purpose of the disclosure on a release of information form in one of eight client records reviewed.
Client #1 was admitted on July 24, 2024 and was active at the time of the inspection. A release of information form to a physician was signed and dated by the client on July 24, 2024; however, there was no purpose of the disclosure documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 chart, the release of information to the Physician without the purpose of the disclosure will be voided. The front desk at this clinic will call the client and inform them about the new release of information form to be completed for the Physician. This new form will have the purpose of disclosure with physician, which is collaborative treatment. The Program Director instructed the front desk to contact client #1 to inform them about the need for a new release for the Physician. The front desk staff of the clinic will contact the client by 12/24/2024 and invite the client to come to the clinic to sign this form by 01/10/2025. The program director provided the new form to the front desk staff.
The program director will ensure this new form is added to the DA Intake packet so that all new clients will sign this form and ensure this deficiency doesn't occur. The Program Director will ensure this task is completed. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to ensure the consent to treatment documentation was obtained as part of the intake procedures in five of five applicable client records reviewed.
Client #1 was admitted on July 24, 2024 and was active at the time of the inspection. There was no consent to treatment documented in the record as of the date of the inspection.
Client #2 was admitted on August 7, 2024 and was active at the time of the inspection. There was no consent to treatment documented in the record as of the date of the inspection.
Client #3 was admitted on August 8, 2024 and was active at the time of the inspection. There was no consent to treatment documented in the record as of the date of the inspection.
Client #7 was admitted on September 25, 2024 and was active at the time of the inspection. There was no consent to treatment documented in the record as of the date of the inspection.
Client #8 was admitted on October 8, 2024 and was active at the time of the inspection. There was no consent to treatment documented in the record 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
A new consent of treatment form was created on 11/19/2024 and added to the Intake packet. All new clients will sign this document along with other documents before starting the treatment. This will prevent this deficiency from occurring with all new clients. This same form is used to get signatures from existing clients. The front desk staff are actively works with all existing clients, calling on their phones and inviting them to come to the clinic to sign the document. Program Director will be responsible for implementing this task. |
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, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of four applicable client records reviewed.
Client #1 was admitted on July 24, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 30, 2024 and the first treatment plan update was due no later than September 30, 2024; however, the update was completed on November 15, 2024.
Client #2 was admitted on August 7, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 14, 2024 and the first treatment plan update was due no later than October 14, 2024; however, the update was not completed as of the date of the inspection.
Client #3 was admitted on August 8, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 15, 2024 and the first treatment plan update was due no later than October 15, 2024; however, the update was not completed 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
The matter was addressed with the substance abuse counselor. Individual supervision was provided for completing the treatment plan every 60th day. A spreadsheet will be shared between substance abuse counselors and supervisors with information on treatment plan due dates, and the supervisor will monitor and remind substance abuse counselors to complete them on time. |