INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 8, 2025 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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705.28 (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 December 2024 through November 2025 fire drill logs, the facility failed to conduct an unannounced fire drill at least once a month.
At the time of the inspection, there was no documentation in the fire drill logs indicating an unannounced fire drill was conducted during the month of March 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill will be conducted every month as required. Quality Asst under the supervision of Admin Director will monitor and ensure this task is completed every month |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records and a discussion with facility staff, the facility failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.
At the time of the inspection, the facility does not keep paper client records, and all paper documentation is to be scanned into the electronic record by the staff in a timely fashion. During the course of the client record review, there was one outpatient client record that was missing all the intake and admission documents and only had treatment plan updates and progress notes documented. Additionally, there was a second, active outpatient client record, with an admission date of October 6, 2025, was briefly reviewed and there was no documentation at all in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff in the drug and alcohol program are instructed to attach paper documents as soon as possible to EHR client record to ensure chart is upto date. A new EHR will be introduced in April 2025 which has better data colelction and better record keeping system.
Supervisor will work with counselors that each case has updated records in the system.
DA supervisor will be responsible for this.
DA counselors received instructions on uploading documents on time on 12/16/2025 |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allows for the identification of client ' s admissions and discharges within a specific time period.
At the time of the inspection, per a review of the client lists provided to the Licensing Representative, the facility was unable to identify the admission and discharge dates for the clients on the list of admitted and discharged clients since the previous licensing inspection Additionally, there were at least 2 clients reviewed that were identified on both the active and the discharged lists given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A clear list of clients with accurate admission and discharge dates will be provided to the auditor by the supervisor during future audits.
The QA staff who prepared the list will receive further training on preparing the list. This training will be completed by 01/31/2026.
DA supervisor/ program director will ensure the corrective action is implemented.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a record review, the facility failed to ensure the documentation of a preliminary treatment and rehabilitation plan during the intake and admission process, in three of seven client records reviewed.
Client #4 was admitted on May 20, 2025 and was discharged on July 21, 2025. There was no documentation, in the record, indicating a preliminary treatment and rehabilitation plan was completed prior to discharge.
Client #6 was admitted on September 11, 2025 and was discharged on November 11, 2025. There was no documentation, in the record, indicating a preliminary treatment and rehabilitation plan was completed prior to discharge.
Client #7 was admitted on September 17, 2025 and was discharged on November 25, 2025. There was no documentation, in the record, indicating a preliminary treatment and rehabilitation plan was completed prior to discharge..
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A preliminary treatment and rehabilitation plan is already been attached to Intake packet as on 12/16/2025. This document is also shared with Substance use counselors to ensure this plan is completed during the admission/ Intake session for all the clients. DA supervisor is responsible for ensuring the corrective action(s) is implemented. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the client's individual treatment and rehabilitation plan in three of four applicable client records reviewed.
Client #1 was admitted on June 11, 2025 and active at time of inspection. The individual treatment and rehabilitation plan was completed on June 30, 2025; however, the plan did not include proposed type of support services.
Client #2 was admitted on August 14, 2025 and active at time of inspection. The individual treatment and rehabilitation plan was completed on August 14, 2025; however, the plan did not include proposed type of support services.
Client #3 was admitted on August 22, 2025 and active at time of inspection. The individual treatment and rehabilitation plan was completed on August 22, 2025; however, the plan did not include proposed type of support services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor instrcuted substance use counselors on 12/12/2025 that all treatment plans and progress notes must clearly identify and include follow-up on applicable support services. On the treatment plan, the 2nd goal will include support services and will be followed upon by the counselor during the individual therapy/ counseling sessions. Supervisor will further reinforce this during the supervision sessions and recommend appropriate support services to meet client's individual needs. |