INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed as there was a portable space heater located in the receptionist office at the time of the inspection.
This is a repeat citation from the January 10, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Space heaters/ portable heaters permanently removed. Receptionist was instructed to not use space heaters and Admin director will monitor this. |
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 an attempted review of the fire drill logs, the facility failed to conduct an unannounced fire drill at least one time a month.
There were no fire drills conducted for the entire January 2022 through November 2022 timeframe reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Since December 2022 every month fire drill will be completed at this facility under the leadership of Admin Director. The need to complete fire drill every month was discussed with COO, maintenance supervisor and maintenance staff. Admin Director will send a reminder at the beginning of the month to maintenance staff about the fire drill. If it is not completed before the last week of the month, admin director will send final reminder to the staff to complete fire drill within the last week of the month. |
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 obtain an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.
Client #1 was admitted on September 24, 2019 and was active at the time of inspection. There was a consent to release information form to the funding source signed by the client that expired on September 24, 2020. There was evidence of disclosures to the funding source during the client's treatment episode after the expiration date; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #4 was admitted on March 10, 2021 and was discharged on July 19, 2022. There was a consent to release information form to the funding source signed by the client that expired on March 10, 2022. There was evidence of disclosures to the funding source during the client's treatment episode after the expiration date; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #5 was admitted on March 15, 2021 and was discharged on August 3, 2022. There was a consent to release information form to the funding source signed by the client that expired on March 15, 2022. There was evidence of disclosures to the funding source during the client's treatment episode after the expiration date; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director instructed DA counselor to contact the clients, request them to come to the clinic to sign the consents as soon as possible. The updated consent forms will be used and they don't expire until 03 months after the discharge date. Program Director will oversee this task and review with DA counselors during supervision. Client #1 was not available for counseling services for the month of December, when he returns this month for services; the consent to release information to the funding source will be completed. Client #4 and #5 are discharged. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client in two of seven client records reviewed.
Client #2 was admitted on March 8, 2022 and was active at the time of inspection. There were release of information forms to a government agency, a funding source, and a transportation agency signed and dated by the client on March 8, 2022; however, there was no documentation that indicated a copy of each consent form was offered to the client.
Client #7 was admitted on October 20, 2021 and was discharged on June 21, 2022. There were release of information forms to a funding source, a laboratory, and a transportation agency signed and dated by the client on October 20, 2021; however, there was no documentation that indicated a copy of each consent form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
According to our records client#2 'Refused' copy of the signed consent form.
Client #7 is discharged.
Program Director instructed DA counselors that a copy of consent forms must be offered to DA clients on 12/19/2022. This will monitored by the program director during the monthly supervisions. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an off-site client death that was reported to the facility on September 20, 2022.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Reporting unusual incidents will be followed as per the LICENSING ALERT 02-2018. The alert 02-2018 was shared with Drug and alcohol counselors and instructed to follow the steps in the alert and also to immediately inform Program Director and Facility Director if an unusual incident occurs. The Program director and Facility Director will ensure that an incident report will be sent to DDAP within 03 days of the incident occurrence. |
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 review and update treatment and rehabilitation plans at least every 60 days in five of six applicable records reviewed.
Client #2 was admitted on March 8, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on March 26, 2022 and an update was due no later than May 26, 2022; however, the update was not completed until July 14, 2022. Additionally, the next treatment plan update was due no later than September 14, 2022; however, the update was not completed until November 25, 2022.
Client #4 was admitted on March 10, 2021 and was discharged on July 19, 2022. A treatment plan update was completed on April 8, 2022 and the next update was due no later than June 8, 2022; however, there was no update completed prior to discharge.
Client #5 was admitted on March 15, 2021and was discharged on August 3, 2022. A treatment plan update was completed on May 2, 2022 and the next update was due no later than July 2, 2022; however, there was no update completed prior to discharge.
Client #6 was admitted on May 19, 2021 and was discharged on July 19, 2022. A treatment plan update was completed on February 6, 2022 and the next update was due no later than April 6, 2022; however, the update was not completed until April 20, 2022.
Client #7 was admitted on October 20, 2021 and was discharged on June 21, 2022. A treatment plan update was completed on January 31, 2022 and the next update was due no later than March 31, 2022; however, there was no update completed prior to discharge.
This is a repeat citation from the January 10, 2022 annual licensing renewal inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director instructed Drug and alcohol counselors to complete the treatment plans every 60 days. If the client is not available, it must be completed without client participation and review the plan with the client when they return for service. A detailed email was sent on 01/05/2023 and will answer their questions, if they have any during supervision scheduled on 01/19/2023.
During the supervision on 01/19/2023 Program director will ask counselors to maintain an excel sheet with all the DA clients on their caseload with date for treatment plan update. Counselors will be asked to review this excel sheet on weekly basis and if anyone is due for treatment plan, it will be duly completed.
This will be monitored by program director. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #4 was admitted on March 10, 2021 and was discharged on July 19, 2022. The individual treatment plan, dated April 8, 2022, indicated the client was to receive one individual counseling session per week and one group counseling session per week. The client's record of service and progress notes indicated that the client had received no individual counseling or group sessions during the months of June 2022 and July 2022.
Client #5 was admitted on March 15, 2021 and was discharged on August 3, 2022. The individual treatment plan, dated May 2, 2022, indicated the client was to receive one individual counseling session biweekly and one group counseling session per week. The client's record of service and progress notes indicated that the client had received no individual counseling or group sessions during the months of June 2022, July 2022, and August 2022.
Client #6 was admitted on May 19, 2021 and was discharged on July 19, 2022. The individual treatment plan, dated April 20, 2022, indicated the client was to receive one individual counseling session biweekly. The client's record of service and progress notes indicated that the client had received no individual counseling sessions during the months of May 2022, June 2022, and July 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will go over this topic by reviewing treatment plans with Drug and alcohol counselors during individual/ group supervision for the month of January 2023. Monitoring the progress will occur during the monthly supervision where Program director will review treatment plans and the services provided. Counselors will be asked to follow all the services as agreed with the client on the treatment plan. The steps the facility will take to ensure this deficiency does not recur is the review of plan that Program director will do during the monthly supervision. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #4 was admitted on March 10, 2021 and was discharged on July 19, 2022.
Client #6 was admitted on May 19, 2021 and was discharged on July 19, 2022.
Client #7 was admitted on October 20, 2021 and was discharged on June 21, 2022.
This is a repeat citation from the January 10, 2022 and February 26, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director informed Drug and alcohol counselors via email on 01/05/2023 that they need to follow up with the client 3-4 weeks after the discharge to check on the well-being and to enquire if they want to re-open case file to start services. The phone call will be documented on client profile. Program Director will go over this topic again during the supervision session in January 2023 and also monitor the progress every month. |
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.
Plans of correction for completing follow-up information as a part of the complete client record on an individual were submitted and approved by the Department for the January 10, 2022 and February 26, 2021 annual licensing inspections. Not completing follow-up information as part of the complete client record was again found to be a deficiency in the December 7, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The two Directors who prepared for the scheduled audit for 12/07/2022 are also supervising the DA counselors which will help in direct monitoring of POC. This is the change that we will be having this year which could increase the implementation efficiency of POC. |