INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 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 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel files, the facility failed to document a written individual training plan, with input from the employee and the supervisor, in three of five personnel records reviewed.
Employee #4 was hired as the medical doctor on February 25, 2019. There was no training plan documented, in the record, for the current training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning February 1, 2022. APM's QA Assistant will complete a quarterly review of our Behavioral Health staff's training plans, including those of new hires to 1) ensure they are up to date, and 2) note progress made toward Training Plan goals. APM's QA Assistant will then send a report to both the clinical supervisors / facility directors and APM's VP Health and Homeless Services / Project Director. Plans will then be reviewed at the end of each calendar quarter.
APM's VP Health will ensure the Medical Director's Training Plan is updated by February 1, 2022. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel files, the facility failed to ensure that the project director obtained at least 12 clock hours of training for the January 2021 through December 2021 training year.
Employee #1 was hired as the project director on July 1, 2020. There was only 9.5 hours of annual trainings documented for the reviewed training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
APM's Project Director (VP Health and Homeless Services) will develop a Training Plan and submit it to his supervisor, APM's COO, as part of his Annual Performance Review. APM's Project Director will then complete at least 12 hours of relevant training during the year. |
705.27 (1) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on physical plant inspection, conducted at approximately 1:00 pm, the facility failed to ensure that there were no insect infestations within the facility as there were multiple dead insects observed throughout various areas of the facility.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The landlord has been made aware of this situation and will repair the 2nd floor ceiling and roof openings and the 1st floor wall opening that allow access to rodents and insects. Then APM will call an exterminator who will fumigate the building to rid it of any insect or rodent infestation. Repairs and fumigation will be done by March 1, 2022.
A vacuum cleaner has already been purchased and is in use by APM's cleaning staff to better clean the carpets where the infestation was found. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel files the facility failed to ensure that the personnel files contained documentation of an annual written individual performance evaluation of which shall be reviewed and signed by the employee in one of three employee records reviewed.
Employee # 1 was hired as the project director on July 1, 2020. There was no documentation that the annual written individual performance evaluation was completed for the review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
APM's COO, the Project Director's supervisor, will complete the Project Director's Annual Performance Evaluation by March 31, 2022 and annually by December 31 thereafter. |
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 for the disclosure of information in the client record in six of seven client records reviewed.
Client #1 was admitted on September 18, 2020 and was active at the time of inspection. There was documentation of billing to the funding source since the client's admission; however, there was no consent to release information form on file prior to the disclosures of information.
Client #3 was admitted August 24, 2020 and was discharged February 19, 2021. There was documentation of billing to the funding source during the client's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
Client #4 was admitted August 26, 2020 and was discharged March 26, 2021. There was documentation of billing to the funding source during the client's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
Client #5 was admitted March 3, 2020 and was discharged March 19, 2021. There was documentation of billing to the funding source during the client's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
Client #6 was admitted February 18, 2020 and was discharged March 5, 2021. There was documentation of billing to the funding source during the client's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
Client #7 was admitted October 8, 2020 and was discharged March 19, 2021. There was documentation of billing to the funding source during the client's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
APM's Consent to Release Information forms were updated in our intake packets in December, 2020. APM's Counselors will review Consents to ensure they are current in their next Treatment Planning session with program participants, beginning February 1, 2022. Facility Directors will review participant files to ensure compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven records reviewed.
Client # 2 was admitted on March 15, 2021 and was active at the time of inspection. The consent to release information form to the funding source, signed and dated by the client on March 15, 2021, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
APM's Consent to Release Information forms were updated in our intake packets to be compliant with 4 Pa. Code 255.5 (b) in December, 2020. APM's Counselors will review Consents to ensure they are current by their next Treatment Planning session with program participants, beginning February 1, 2022. Facility Directors will review participant files to ensure compliance. |
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 document a complete client record, which is to include follow-up information, in four of four applicable client records reviewed.
Client #3 was admitted August 24, 2020 and was discharged February 19, 2021. There was no follow-up information documented in the record at the time of the inspection.
Client #4 was admitted August 26, 2020 and was discharged March 26, 2021. There was no follow-up information documented in the record at the time of the inspection.
Client #5 was admitted March 3, 2020 and was discharged March 19, 2021. There was no follow-up information documented in the record at the time of the inspection.
Client #7 was admitted October 8, 2020 and was discharged March 19, 2021. There was no follow-up information documented in the record at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
APM Counselors will follow up with discharged participants by telephone one month after discharge beginning February 1, 2022 and record the attempt and any conversation that may ensue in a non-billable note. Discharges clients who did not receive follow up will be contacted during the month of February.
Clinical Supervisors will first, instruct APM's Counselors to follow up by telephone within one month of client discharge and review Discharges at least quarterly with APM's Counselors to ensure this follow up is taking place. This will ensure this does not happen again. |