INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6-7, 2020 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop a written policy to address relapse of recovering clinical personnel.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
In collaboration with the Human Resources Director, the Facility/Project Director will develop a written policy to address the relapse of recovering clinical personnel. The Facility/Project Director will ensure the implementation of this policy. To ensure all staff is aware, a staff meeting will be held to inform everyone of the policy. The policy will be completed by March 31, 2020. The staff meeting will be held by April 6, 2020. The Facility/Project director and Quality Assurance Assistant (QAA) will monitor adherence to this policy. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the policy and procedure manual, the manual states that feedback forms should be completed after each training. After a review of personnel files, the facility failed to complete feed back forms after each training.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Effective March 9, 2020, all staff will submit training feedback forms with every training certificate. All training certificates will be submitted to the Clinical Supervisor (CS). The CS will ensure that a training feedback form is completed and attached to the training certificate. Once the documents are verified, they will be submitted to QAA for review. Once QAA has confirmed the training feedback form is completed and attached to the training certificate, the forms will be filed in the staff personnel file. QAA will conduct random chart audits to monitor that this policy is being adhered to. |
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 personnel records, the facility failed to complete an annual written individual training plan for each employee.
Employee #1 was hired as project director on June 25, 2018 and was still in that role at the time of inspection. The last training plan in the personnel record was from July 1, 2018-June 30, 2019. The update was not signed off on by the employee and supervsior at the time of inspection.
Employee #2 was hired as facility director on April 2, 2015 and was still in that role at the time of inspection. The last training plan in the personnel record was from July 1, 2018-June 30, 2019. The update was not signed off on by the employee and supervsior at the time of inspection.
Employee #3 was hired as counselor on June 11, 2016 and was still in that role at the time of inspection. The last training plan in the personnel record was from July 1, 2018-June 30, 2019. The update was not signed off on by the employee and supervsior at the time of inspection.
Employee #4 was hired as counselor on December 18, 2018 and was still in that role at the time of inspection. The last training plan in the personnel record was from July 1, 2018-June 30, 2019. The update was not signed off on by the employee and supervsior at the time of inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On March 3, 2020, all Clinical Supervisors (CS) and the Quality Assurance Assistant (QAA) were informed that individual training plans are to be completed in collaboration with the employee and signed by both the employee and the CS annually on the 1st business day of June of the current year. The Facility/Project Director and QAA will review staff credentialing files on a bi-annual basis to monitor compliance with this policy. |
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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #4received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on January 2, 2019 and was due to have the communicable disease trainings no later than January 2, 2020 . There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A full and complete audit of all training requirements for all behavioral health staff will be completed by QAA on March 6, 2020. Each CS and Facility/Project Director will be notified in writing of any missing training with a completion date. Beginning March 9, 2020, QAA will review new staff training plans every thirty days during the six-month probationary period or until the training requirements are met. Any training non-compliance will be reported to both the CS and the employee for immediate correction. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
A review of the January 2019 through December 2019 fire drill logs was conducted during the onsite inspection. The facility failed to conduct fire drills on different times of the day as seven of the twelve fire drills were conducted at 11:45 am. Additionally, eleven of the tweleve fire drills were conducted within the last 10 days of the month.
The findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Effective March 9, 2020, the Facility/Project Director will work in close collaboration with the Facilities Director to ensure that fire drills are conducted at different times of the day and different days of the week every month. QAA and the Facility/Project Director will monitor this process every month 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 disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 2, and 3.
4 Pa. Code 255.5(b) Restrictions. - states: Information released to judges, probation or parole officers, insurance company helath or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is ot is not in treatment.
(2)The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client
(5) A short statement as to whether or not the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Client #1 was admitted on August 27, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on November 13, 2019 to the funding source that allowed for the release of psych eval, medical history, Biopsychosocial, discharge summary, labs, aftercare, treatment plans, integrated summary and billing claims.
Client #2 was admitted on July 31, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on November 26, 2019 to the funding source that allowed for the release of psych eval, medical history, Biopsychosocial, discharge summary, labs, aftercare, treatment plans, integrated summary and billing claims.
Client #3 was admitted on July 6, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on December 23, 2019 to the funding source that allowed for the release of psych eval, medical history, Biopsychosocial, discharge summary, labs, aftercare, treatment plans, integrated summary and billing claims.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will oversee the revision and implementation of the confidentiality form to ensure that it adheres to the restrictions under 4 PA Code 255.5. The revision will be completed by March 23, 2020, and will be included in the intake packet. Existing clients will be provided with the updated form by March 31. 2020 to sign and file in the client record. QAA will conduct random chart audits to monitor that each client record contains the revised form. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records and the policy and procedure manual, the facility's client rights policy failed to include documentation of all the required client rights, including retaining civil rights and liberties except as provided by statute.
This is a repeat citation. The facility was previously cited for noncompliance with this regulation during the January 2-3, 2019 licensure inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility/Project Director will oversee the revision of the client's rights form and ensure that it is revised to meet the licensure requirements. The revision will be completed by March 31, 2020, and included in the intake packets for all new clients. All current clients will be provided with the revised form by April 18, 2020. To ensure ongoing compliance with the revised form and updated policy, QAA will conduct random chart audits to monitor this process. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of seven client records and the policy and procedure manual the facility's client rights policy failed to include documentation of all the required client rights, including the right to appeal decision limiting access to their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility/Project Director will oversee the revision of the client's rights form and ensure that it is revised to meet the licensure requirements. The revision will be completed by March 31, 2020, and included in the intake packets for all new clients. All current clients will be provided with the revised form by April 18, 2020. To ensure ongoing compliance with the revised form and updated policy, QAA will conduct random chart audits to monitor this process. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of seven client records and the policy and procedure manual, the facility's client rights policy failed to include documentation of all the required client rights, including the right to request the correction of inaccurate, irrelevant, outdated or incomplete information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility/Project Director will oversee the revision of the client's rights form and ensure that it is revised to meet the licensure requirements. The revision will be completed by March 31, 2020, and included in the intake packets for all new clients. All current clients will be provided with the revised form by April 18, 2020. To ensure ongoing compliance with the revised form and updated policy, QAA will conduct random chart audits to monitor this process. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of seven client records and the policy and procedure manual, the facility's client rights policy failed to include documentation of all the required client rights, including the right to submit rebuttal data or memoranda to their own records.
This is a repeat citation. The facility was previously cited for noncompliance with this regulation during the January 2-3, 2019 licensure inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility/Project Director will oversee the revision of the client's rights form and ensure that it is revised to meet the licensure requirements. The revision will be completed by March 31, 2020, and included in the intake packets for all new clients. All current clients will be provided with the revised form by April 18, 2020. To ensure ongoing compliance with the revised form and updated policy, QAA will conduct random chart audits to monitor this process. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develope and implement a policy and procedure to address the unusual incident of physical assault or sexual assault by staff or a client.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of physical assault or sexual assault by staff or a client. The new policy will be completed and implemented by March 31, 2020. Education will be provided to staff in regularly scheduled staff meetings. The Facility/Project Director will monitor adherence to all new procedures. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address the unusual incident of selling or use of illicit drugs on the premises.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of selling or use of illicit drugs on the premises. The new policy will be completed and implemented by March 31, 2020 |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develope and implement a policy and procedure to address the unusual incident of death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by the facility, for ambulatory services. The new policy will be completed and implemented by March 31, 2020
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709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address the unusual incident of significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of significant disruption of services due to disasters such as fire, storm, flood or other occurrences which closes the facility for more than 1 day. The new policy will be completed and implemented by March 31, 2020. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address the unusual incident of theft, burglary, break-in or similar incident at the facility.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of theft, burglary, break-in or similar incident at the facility. The new policy will be completed and implemented by March 31, 2020. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address the unusual incident of event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of an event at the facility requiring the presence of police, fire or ambulance personnel. The new policy will be completed and implemented by March 31, 2020. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address the unusual incident of fire or structural damage to the facility.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of fire or structural damage to the facility. The new policy will be completed and implemented by March 31, 2020.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure to address the unusual incident of outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that addresses unusual incidents of an outbreak of a contagious disease requiring the Centers for Disease Control (CDC) notification. The new policy will be completed and implemented by March 31, 2020. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure that includes prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will work in collaboration with the Human Resources Director to develop a policy and procedure that includes prompt review and identification of the causes directly or indirectly responsible for the unusual incident. The new policy will be completed and implemented by March 31, 2020. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure that includes implementation of a timely and appropriate corrective action plan, when indicated.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will oversee the revision of the policy and procedure manual to includes implementation of a timely and appropriate corrective action plan when indicated. The new policy and procedure will be completed and implemented by March 31, 2020. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop and implement a policy and procedure that includes ongoing monitoring of the corrective action plan.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility/Project Director will oversee the revision of the policy and procedure manual to include ongoing monitoring of the corrective action plan. The new policy will be completed, implemented and monitored by the Facility/Project Director and QAA on a quarterly basis. |
709.92(a) 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:
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Observations
Based on a review of seven client records and the policy and procedure manual, the facility failed to ensure that all clients received a comprehensive treatment plan within 30 days of admission, as directed in the policy and procedure manual.
Client #1 was admitted on August 27, 2019 and was still active at the time of inspection. Client #1 received an initial treatment plan on August 27, 2019 and did not receive a comprehensive treatment plan until December 27, 2019.
Client #2 was admitted on July 31, 2019 and was still active at the time of inspection. Client #2 received an initial treatment plan on August 6, 2019 and did not receive a comprehensive treatment plan until September 30, 2019.
Client #4 was admitted on September 17, 2019 and was still active at the time of inspection. Client #4 received an initial treatment plan on September 4, 2019 and did not receive a comprehensive treatment plan until October 28, 2019.
Client #5 was admitted on November 25, 2019 and was discharged on February 4, 2020. Client #5 received an initial treatment plan on November 25, 2019 and did not receive a comprehensive treatment plan by the time of discharge.
Client #6 was admitted on May 15, 2019 and was discharged on November 1, 2019. Client #6 received an initial treatment plan on May 17, 2019 and did not receive a comprehensive treatment plan by the time of discharge on November 1, 2019.
Client #7 was admitted on August 7, 2019 and was discharged on November 11, 2019 . Client #7 received an initial treatment plan on August 9, 2019 and did not receive a comprehensive treatment plan by the time of discharge on November 11, 2019.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Effectively March 6, 2020, QAA and the CS will monitor all intakes within the first thirty days to ensure that recovery plans are completed in the appropriate allotted time frames. The CS will also provide weekly supervision with chart audits to provide coaching to the counselors in real-time. These oversight and supervisory mechanisms will serve to eliminate this deficiency. |