INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 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 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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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 the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics within the regulatory timeframe in two of five applicable personnel records reviewed.
Employee #4, a receptionist hired on February 1, 2020, was due to receive both the HIV/AIDS training and the TB/STD training no later than February 1, 2022; however, there was no documentation that either the HIV/AIDS training or the TB/STD training were completed as of the date of the inspection.
Employee #5, a receptionist hired on February 1, 2020, was due to receive both the HIV/AIDS training and the TB/STD training no later than February 1, 2022; however, there was no documentation that either the HIV/AIDS training or the TB/STD training were completed as of the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Admin Director/ Facility Director will ensure that all staff who are required to take these trainings complete them on time. Admin Director/ Facility Director will check DDAP trainings website time to time to find the trainings and to ensure registering staff for these trainings. Since these trainings are not frequent enough and gets sold out, admin director will ensure trainings are completed by all required staff within the next 06 months. |
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 fire drill logs from January 2022 through November 2022, the facility failed to conduct an unannounced fire drill at least one time a month during the months of January, May, July, August, October and November 2022.
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. |
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 2022 through November 2022 fire drill logs, the facility failed to ensure that their written fire drill log included the exit route used during drills and the number of persons in the facility at the time of the drill.
The February, March, April, June, and September 2022 fire drill logs did not include documentation of which exit route was used during the drill. Additionally, the March and April 200 fire drill logs did not include documentation of the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff (receptionist, maintenance person) involved was instructed to complete the documentation as needed for the fire drill on 12/14/2022. Admin Director will be responsible in reviewing and ensuring document is completed for all monthly fire drills. |
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 18, 2020 and was active at the time of inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #2 was admitted on March 15, 2021 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 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.
Client #4 was admitted on October 20, 2022 and was active at the time of inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the January 12, 2022 and September 17, 2020 annual licensing renewal inspections.
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. |
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 each client consent to release information form was offered to the client in three of seven client records reviewed.
Client #5 was admitted on March 24, 2022 and was active at the time of inspection. There were release of information forms to a laboratory and a transportation agency signed and dated by the client on March 24, 2022; however, there was no documentation that indicated a copy of either consent form was offered to the client.
Client #6 was admitted on October 20, 2022 and was active at the time of inspection. There were release of information forms to a funding source, a laboratory, a government agency and a transportation agency signed and dated by the client on October 20, 2022; however, there was no documentation that indicated a copy of any of the consent forms were offered to the client.
Client #7 was admitted on October 21, 2022 and was active at the time of inspection. There were release of information forms to a funding source, a laboratory, a government agency and a transportation agency signed and dated by the client on October 21, 2022; however, there was no documentation that indicated a copy of any of the consent forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director instructed DA counselor 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. |
709.92(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 that treatment rehabilitation plans are reviewed and updated at least every 60 days in four of four applicable records reviewed.
Client #1 was admitted on September 18, 2020 and was active at the time of inspection. A treatment plan update was completed on February 7, 2022 and the next update was due no later than April 7, 2022; however, the update was not completed until April 20, 2022. Additionally, the next update was due no later than June 20, 2022; however, the update was not completed until July 15, 2022.
Client #2 was admitted on March 15, 2021 and was active at the time of inspection. A treatment plan update was completed on April 18, 2022 and the next update was due no later than June 18, 2022; however, the update was not completed until September 8, 2022.
Client #3 was admitted on January 6, 2021 and was active at the time of inspection. A treatment plan update was completed on March 31, 2022 and the next update was due no later than May 31, 2022; however, the update was not completed until September 12, 2022
Client #5 was admitted on March 24, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on April 1, 2022 and the first update was due no later than June 1, 2022; however, the update was not completed until June 22, 2022. Additionally, the next update was due no later than August 22, 2022; however, the update was not completed until September 4, 2022.
These findings were 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 for the month of January.
During the supervision Program director will ask counselors to maintain an excel sheet with all the DA clients on their caseload with date for treatment plan update from January 2023 onwards. 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 during monthly supervisions.
The steps the facility will take to ensure this deficiency does not recur is the review of date of plan for each client that Program director will do during monthly supervision |
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 obtaining an informed and voluntary consent to release information form prior to the disclosure of client information were submitted and approved by the Department for the January 12, 2022 and September 17, 2020 annual licensing inspections. Obtaining an informed and voluntary consent to release information form prior to the disclosure of client information was again found to be a deficiency in the December 9, 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 12/09/2022 are also supervising the DA counselors which will help in direct monitoring of POC. This is the difference that we will be having this year which could increase the implementation efficiency of POC. |