INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26th, 2021 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 Puertorriqueno En Marcha Proyetco 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of five personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #1 received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #1 was hired as the project director on June 25, 2018 and was due to have the communicable disease trainings no later than June 25, 2020. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Employee #1, a Licensed Professional Counselor, is currently on FMLA. When employee #1 returns from FMLA, they will be required to schedule 4 hours of TB / STD training within the first six months following their return. The Facility/Project Director will monitor Employee #1's attempts to enroll in a TB/STD until they take the training and receive the certificate for this training. |
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 fire drill log, the facility failed to conduct unannounced monthly fire drills as the facility has not conducted a fire drill since February 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Unannounced monthly fire drills will be scheduled every month, starting immediately. The Facility/Project Director will monitor adherence to our fire drill procedure. |
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 seven client records, the facility failed to include the specific information to be released in all seven client records. All seven client records continued signed and dates release for funding sources, transportation and drug screening that did not include what information could be released.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
APM will provide separate Releases of Information for participants to sign for funding sources, transportation, drug screening and medical care providers. APM's Quality Improvement Team will monitor compliance through random chart audits. |
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
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of physical assault or sexual assault by staff or a client.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of physical
assault or sexual assault by staff or a client. The new policy will be completed and implemented by March 31, 2021. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures.
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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
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of selling or use of illicit drugs on the premises.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of selling or use of illicit drugs on the premises. The new policy will be completed and implemented by March 31, 2021. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures. |
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
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of 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.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of death or serious injury due to trauma, suicide, medication error or
unusual circumstances while in residential treatment or, when known by the facility, for ambulatory services. The new policy will be completed and implemented by March 31, 2021. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures. |
709.34 (a) (4) 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:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of significant disruption of services due to disasters such as fire, storm, flood or other occurrences which closes the facility for more than 1 day. The new policy will be completed and implemented by March 31, 2021. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures.
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709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of theft, burglary, break-in or similar incident at the facility.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of theft, burglary, break-in or similar incident at the facility. The new policy will be completed and implemented by March 31, 2021. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures. |
709.34 (a) (6) 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:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of an event at the facility requiring the presence of police, fire or ambulance personnel. The new policy will be completed and implemented by March 31, 2021. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures. |
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
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of a fire or structural damage to the facility.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of fire or structural damage to the facility. The new policy will be
completed and implemented by March 31, 2021. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures.
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709.34 (a) (8) 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:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the unusual incident of an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from inspection dated February 7, 2020.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses
unusual incidents of an outbreak of a contagious disease requiring the Centers for Disease Control (CDC) notification. The new policy will be completed and implemented by March 31, 2021.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to provide and document a narcotic treatment physician made a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician failed to document in three patient records the basis for the determination of current dependency and evidence of a 1 year history of addiction in three patient records.
Patient #2 was admitted on June 1, 2020 and was still active at the time of the inspection
Patient #3 was admitted on December 14, 2020 and was still active at the time of the inspection.
Patient #4 was admitted on July 22, 2019 and was still active at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Plan of Correction:
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment.
Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination.
Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real- time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental
Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19- dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in- person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis.
APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of four patient records, the facility failed to ensure that one patient received an initial drug-screening urinalysis.
Patient #2 was admitted on June 1, 2020 and was still active at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Plan of Correction:
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment.
Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination.
Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real- time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental
Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19- dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in- person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis.
APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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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 seven client records, the facility failed to provide follow up information in two client records.
Client #6 was admitted on December 6, 2019 and discharged on October 27, 2020.
Client #7 was admitted on October 24, 2020 and discharged on December 3, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The client's counselor will do a non-billable follow up, shown in their notes, on clients who depart the program with 15, 30, 60, and 90 days of their departure, effective immediately. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews. |