INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 9, 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 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:
|
Plan of Correction
|
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.
|
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 indicating an unannounced fire drill was conducted during the months of March 2025 and September 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Fire drill will be conducted every month as required. Admin Director will monitor and ensure this task is completed every 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.
|
Observations
Based on a review of the December 2024 through November 2025 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the documentation of 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 drills, problems encountered and whether the fire alarm or smoke detector as operative.
At the time of the inspection, the fire drill logs for the months of February 2025, April 2025, June 2025, and November 2025 did not include the amount of time it took for evacuation. Additionally, the fire drill logs for the months of February 2025 and April 2025 did not include which exit route was used during the completed drill.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 12/10/2025, staff involved in fire drill received instructions/ training on the correct way completing the fire drill logs by including 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 drills, problems encountered and whether the fire alarm or smoke detector as operative. Staff were also instructed to use both exits in the building during the fire drill. QA responsible for ensuring the corrective action(s) is implemented. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the December 2024 through November 2025 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
At the time of the inspection, all the fire drills conducted, during the reviewed period, used the front door exit as the sole exit route used.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 12/10/2025 all staff involved in fire drill received instruction to use both exits during the fire drill. Staff were instructed to use the exit closest and safest to exit. QA who is responsible for ensuring the corrective action(s) is implemented. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client records, the facility failed to ensure a consent to treatment was documented in the record, as a part of the intake and admission process, in one of three applicable client records reviewed.
Client #2 was admitted on September 11, 2025 and was active at the time of the inspection. There was no consent to treatment documented, in the record, as of the date of the inspection.
This is a repeat citation from the November 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The staff providing Intake packet to clients for admission was instructed to use the correct packet that has the consent to treatment document and substance use counselors were instructed to specifically check if this document is completed by the client during the Intake session.These instructions were provided on 12/12/2025. DA supervisor is responsible for ensuring the corrective action(s) is implemented. |