INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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 the physical plant inspection on January 8, 2018 at approximately 1 pm., the facility failed to ensure that all heaters in the facility were permanently mounted or installed. The middle counseling office located on the right side of the hallway had a space heater sitting beside the entrance to the office on the floor.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately all counselors have been notified verbally and in writing that space heaters are not allowed in offices.
Effective immediately, QA will conduct unannounced facility inspections to ensure that no one is using space heaters. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of 5 client records, the facility failed to obtain a valid consent to release information form in 1 client record.
Client #2 was admitted on 8/29/16 and was active at the time of inspection. There were separate consent to release forms to a laboratory, transportation agency and an insurance provider, all three dated 8/29/16. However, none of the consent forms were signed by the client prior to the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On January 10, 2018 intake staff and counselors were instructed on the importance of acquiring all signatures from clients at the time of service.
Effective 1/12/2018 all client records will be reviewed by the front desk staff and clinical supervisor. During these reviews administrative paperwork will be checked to ensure that all appropriate signatures and dates are affixed according to regulation. |
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 5 client records, client record #1, 2, 3, 4 and 5 had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.
Client #1 was admitted on 2/8/16 and was active at the time of inspection. A treatment plan update was completed 1/23/17 and the next update was due no later than 3/23/17. However, the update was not completed until 4/6/17.
Client #2 was admitted on 8/29/13 and was active at the time of inspection. A treatment plan update was completed 11/15/16 and the next update was due no later than 1/15/17. However, the update was not completed until 4/14/17.
Client #3 was admitted on 11/29/16 and was an active patient at time of inspection. A treatment plan was completed 6/20/17 and the next update was due no later than 8/20/17. However, the update was not completed until 10/20/17. Additionally, a treatment plan update was completed 10/20/17 and the next update was due no later than 12/20/17. However, the update was not completed until 1/2/18.
Client #4 was admitted on 3/13/17 and was discharged on 1/3/18. A treatment plan update was completed 3/13/17 and the next update was due no later than 5/13/17. However, the update was not completed until 8/25/17. Additionally, a treatment plan update was completed 8/25/17 and the next update was due no later than 10/25/17. However, the update was not completed until 12/14/17.
Client #5 was admitted on 12/27/16 and was discharged on 7/17/17. A treatment plan was completed 12/27/16 and the update was due no later than 2/27/17. However, the update was not completed until 4/17/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On January 10, 2018 counselors meet with the Clinical Supervisor. During this meeting, counselors were provided coaching on maintaining updated treatment plans.
Staff were educated on engagement skills and treatment plan mapping. Staff were instructed to update the treatment plan early in cases where clients have sporadic attendance.
Staff will take immediate steps to update current active cases and will map treatment plans with attendance habits of clients to avoid these such deficiencies in the future.
Effective January 12, 2018, D/A counselors will maintain a treatment plan log on each client and use this log to track treatment plan updates.
QA will conduct quarterly chart audits and the Clinical Supervisor will conduct monthly chart audits to ensure that these deficiencies do not continue. |