INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's January 2023 through December 2023 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
There were no fire drills conducted during the months of June 2023 and July 2023 documented in the facility's fire drill log.
This is a repeat citation from the December 9, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill will be completed as required every month at the clinic. This task will be monitored by Admin Director and ensured it is completed as per the protocol. |
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
Based on a review of the facility's January 2023 through December 2023 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the exit route used.
Every fire drill log reviewed did not include which exit route was used during the drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill team will be educated about the need to include the exit route used during the drill on the signing sheet. Admin Director will monitor and ensure this task is completed upon every fire drill. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's January 2023 through December 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day.
Every fire drill log reviewed indicated that the drills were conducted between 10:00 am and 12:35 pm; however, the facility's hours of operation are Monday through Friday from 7:00 am to 5:00 pm.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill team will be educated about the need to conduct fire drills at different times of the day taking into consideration the operation hours (7:00 am to 5:00pm). Admin Director will implement and monitor this task by monitoring the time of fire drill for each month and ensure the following month fire drill is different from the previous month. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director reviewed the DA policies and procedures manual on 01/24/2024 and signed after review. In the future Program Director will review the policies and procedure manual end of each year and update any policies and sign after the review. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 2 was admitted on March 8, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on March 8, 2022 and expired on March 8, 2023. A new release of information form to the funding source was signed on August 1, 2023. There was evidence of disclosures to the funding source after the release of information form expired on March 8, 2023 and prior to the new release form being signed on August 1, 2023.
This is a repeat citation from the September 17, 2020, January 12, 2022, and December 9, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 has signed a release of information form to the funding source on 12/02/2022 as per our records on our EHR Credible which was available during the time of audit on Jan 3rd 2024. This form is valid until 3 months after the discharge. Another form was completed on 08/01/2023. Our records show there was no lapse and a valid release form was there on client chart all the time.
All the cases will be reviewed by PD/ Supervisor with DA counselor during supervision to ensure voluntary consent to release information is completed on time. Program Director/ supervisor will be in-charge of this responsibility. |
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 the disclosure is made to on a consent to release information form in one of seven client records reviewed.
Client # 4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The record included a blank release of information form that was signed by the client on July 10, 2023; however, the release form did not include the name of a person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #4: The release of information without the name of a person, agency, or organization to whom the disclosure would be made will be voided
Program Director/ supervisor will train the DA counselors about completing a consent to release information in it's entirety before both parties sign on it. DA counselors will also be educated on not signing a document if name of a person, agency, or organization to whom the disclosure is not included. If the document is not applicable to the client, it will be removed or voided. Program Director/ supervisor will assume the responsibility for this task and monitor during supervision sessions.
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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 consent to release information forms in two of seven client records reviewed.
Client # 4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The release of information form to an emergency contact was signed by the client on July 10, 2023, but the release form did not include the specific information to be disclosed.
Client # 5 was admitted on April 25, 2023 and was discharged on July 25, 2023. The release of information form to an emergency contact was signed by the client and witness on April 25, 2023, but the release form did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure this deficiency does not occur, a new consent to release information form will be used with the recommended changes. The form will include the list of information that client can review and decide what they would like to release and check off the ones they agree to release. The review and updating of this form will be completed by Program director/ supervisor.
The existing incomplete form in the chart for client #4 discharged on October 12, 2023 is already invalid since 3 months past the discharge date. The existing incomplete form in the chart for client #5 discharged on July 25, 2023 is already invalid since 3 months past the discharge date. |
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 consent to release information forms in two of seven client records reviewed.
Client # 4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The record contained a blank release of information form that was signed by the client on July 10, 2023; however, the release form did not include the purpose of the disclosure.
Client # 5 was admitted on April 25, 2023 and was discharged on July 25, 2023. The release of information form to an emergency contact was signed by the client and witness on April 25, 2023; however, the release form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent to release information for emergency contact will be replaced with a new consent form with the recommended changes. ALL the ROI will be replaced with a new one, which has "purpose of the disclosure" added. The new form will include the purpose of the disclosure. The new form will be used for existing and for new admissions to avoid this in the future. Program director/ supervisor will be in charge and monitor this task.
Client # 5 was admitted on April 25, 2023 and was discharged on July 25, 2023 and thus the ROI has expired.
Client # 4 was admitted on July 10, 2023 and was discharged on October 12, 2023 and thus the ROI has expired.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in two of two applicable client records reviewed.
Client #4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
Client #5 was admitted on April 25, 2023 and was discharged on July 25, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In the clients rights form, the acknowledgement that the clients \ have been notified of their right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment, will be included. This new form will be reviewed and signed by all the existing clients and any new clients in the future. Program director/ supervisor will update the document with this acknowledgement/ information and ensure it is implemented. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of ethnicity in two of two applicable client records reviewed.
Client #4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
Client #5 was admitted on April 25, 2023 and was discharged on July 25, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
A written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of ethnicity will be included in the admission forms for new clients. The existing clients will receive the updated form with the recommended changes and will have the opportunity to review and sign during their in-person visit in the next 45 days. Program director/ supervisor will ensure this new form will be used for all existing and new clients to avoid the deficiency happening in the future. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in two of two applicable client records reviewed.
Client #4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
Client #5 was admitted on April 25, 2023 and was discharged on July 25, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director will be added to the admission documents. Program director/ supervisor will be in charge of this task. All Intakes/ admission documents are revised and approved by supervisor. The DA supervisor will ensure this deficiency will not reoccur |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in two of two applicable client records reviewed.
Client #4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
Client #5 was admitted on April 25, 2023 and was discharged on July 25, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records will be added to admission documents. Program director/ supervisor will be in charge of this task. All Intakes/ admission documents are revised and approved by supervisor. The DA supervisor will ensure this deficiency will not reoccur. Existing clients will have the opportunity to review and sign the updated documents on this matter. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in two of two applicable client records reviewed.
Client #4 was admitted on July 10, 2023 and was discharged on October 12, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
Client #5 was admitted on April 25, 2023 and was discharged on July 25, 2023. The client rights acknowledgement sign-off form, in the client record, did not include acknowledgement of this specific client right.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records will be added to admission documents. Program director/ supervisor will be in charge of this task. All Intakes/ admission documents are revised and approved by supervisor. The DA supervisor will ensure this deficiency will not reoccur. Existing clients will have the opportunity to review and sign the updated documents on this matter. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was submitted and approved by the Department for the September 17, 2020, January 12, 2022, and December 9, 2022 annual licensing inspections. Not completing a voluntary consent to release form prior to the disclosure of information was again found to be a deficiency in the January 3, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An informed and voluntary consent to release information form prior to the disclosure of information will be completed before releasing any information. Program Director/ Supervisor will conduct random chart review to ensure POC that are approved are implemented in the client charts.
Program director will review POC once every 06 months with Admin Director to ensure the approved POC are implemented.
Program Director will be in-charge of this task. |