INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13-14, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. 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.
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Plan of Correction
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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
The facility's administrative records were reviewed on May 13-14, 2019, for the licensing renewal inspection. Fire drill logs were reviewed for the period of June 2018 - April 2018. Based on a review of these logs, the facility failed to ensure that each fire drill log recorded the following: the amount of time it took for evacuation, the exit route used, and the number of people in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Behavioral Health staff will be trained on the proper procedures associated with the full complete the fire drill form. The training will consist of reviewing the entire form line by line and showing staff what goes in each line. Quality Assurance will conduct the training by July 1, 2019 to include but not limited to the amount of time it took for evacuation, the exit route used, and the number of people in the facility at the time of the fire drill. Quality assurance will following up on the proper completion of the fire drill form on a monthly basis. Any deficiencies in the fire drill form completion will be reported to the Clinical Director and Clinical Supervisors for correction within 5 business days. |
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
The facility's administrative records were reviewed for the licensing renewal inspection conducted on May 13-14, 2019. Based on this administrative review, the facility failed to document the project director's written signature on the written manual delineating project policies and procedures.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective June 3, 2019 the Facility Director has signed a written signature on the written manual delineating project policy and procedures. This practice will continue on an ongoing basis to ensure that each staff person working on this project signs a written signature on the written manual delineating project policy and procedures. Quality Assurance will monitor this practice on a monthly basis to ensure that appropriate signatures are present immediately. |
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
The facility's administrative records were reviewed for the licensing renewal inspection conducted on May 13-14, 2019. Based on this administrative review, the project failed to develop written policies and procedures on client rights that were inclusive of clients receiving drug and alcohol treatment services.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written policy and procedure on client rights that are inclusive of clients receiving drug and alcohol treatment services.
The new policy and procedure will be written by July 1, 2019. Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility's administrative records were reviewed on May 13-14, 2019, for the licensing renewal inspection. Based on a review of the facility's policy and procedures manual, the facility failed to ensure that their incident reporting policy incorporated a response to incidents involving sexual assault by a staff member or a client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written incident reporting policy that incorporates a response to incidents involving sexual assault by a staff member or a client.
The new policy and procedure will be written by July 1, 2019. Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility's administrative records were reviewed on May 13-14, 2019, for the licensing renewal inspection. Based on a review of the facility's policy and procedures manual, the facility failed to ensure that their incident reporting policy incorporated a response to incidents involving the use of illicit drugs on the premises.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written incident reporting policy that incorporates a response to incidents involving the use of illicit drugs on the premises.
The new policy and procedure will be written by July 1, 2019. Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
The facility's administrative records were reviewed on May 13-14, 2019, for the licensing renewal inspection. Based on a review of the facility's policy and procedures manual, the facility failed to ensure that their incident reporting policy incorporated a response to incidents involving death due to trauma or medication error, and also incidents involving serious injury due to trauma, medication error, or unusual circumstances.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written incident reporting policy that incorporates a response to incidents involving death due to trauma or medication error, and also incidents involving serious injury due to trauma, medication error, or unusual circumstances.
The new policy and procedure will be written by July 1, 2019. Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
The facility's administrative records were reviewed on May 13-14, 2019, for the licensing renewal inspection. Based on a review of the facility's policy and procedures manual, the facility failed to ensure that their incident reporting policy incorporated a response to incidents involving fire or structural damage to the facility.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written incident reporting policy that incorporates a response to incidents involving fire or structural damage to the facility.
The new policy and procedure will be written by July 1, 2019. Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current.
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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
The facility's administrative records were reviewed on May 13-14, 2019, for the licensing renewal inspection. Based on a review of the facility's policy and procedures manual, the facility failed to ensure that their incident reporting policy identified measures implemented for the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written incident reporting policy that identifies measures implemented for the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
The new policy and procedure will be written by July 1, 2019. Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility's administrative records were reviewed for the licensing renewal inspection conducted on May 13-14, 2019. Based on a review of the facility's policy and procedures manual, the facility failed to ensure that their incident reporting policy addressed the implementation of a timely and appropriate corrective action plan, when necessary.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written incident reporting policy that addresses the implementation of a timely and appropriate corrective action plan, when necessary.
The new policy and procedure will be written by July 1, 2019. Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility's administrative records were reviewed for the licensing renewal inspection conducted on May 13-14, 2019. Based on a review of the facility's policy and procedures manual, the facility failed to ensure that their incident reporting policy identified measures used for the ongoing monitoring of a corrective action plan.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Quality Assurance will develop a written incident reporting policy that identifies measures used for the ongoing monitoring of a corrective action plan.
The new policy and procedure will be written by July 1, 2019.
Quality Assurance will continue to monitor policy and procedure changes, modifications and revisions on a quarterly basis and as needed to ensure that APM program manual remains up to date and current.
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