INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2024 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 January 2023 through December 2023 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.There were no fire drills conducted during the months of June 2023 and July 2023 documented in the facility's fire drill log. This is a repeat citation from the December 7, 2022 annual licensing inspection.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. 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.
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Observations
Based on a review of the facility's January 2023 through December 2023 fire drill logs, the facility failed to maintain a written fire drill record, which is to include the exit route used.Every fire drill log reviewed did not include which exit route was used during the drills. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill team will be educated about the need to include the exit route used during the drill on the signing sheet. Admin Director will monitor and ensure this task is completed upon every fire drill. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project failed to ensure that the project director annually updated and signed the written manual delineating the project's policies and procedures. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director reviewed the DA policies and procedures manual on 01/24/2024 and signed after review. In the future Program Director will review the policies and procedure manual end of each year and update any policies and sign after the review.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information forms in three of seven client records reviewed. Client # 1 was admitted on April 21, 2023 and was still active at the time of the inspection. There was a blank release of information form that was signed by the client on April 21, 2023; however, the release form did not include the name of the person, agency, or organization to whom the disclosure would be made. Client # 3 was admitted on April 25, 2023 and was still active at the time of the inspection. There was a release of information form to another treatment provider that was signed by the client on April 25, 2023; however, the release form did not include the name of the person, agency, or organization to whom the disclosure would be made. Client # 7 was admitted on May 19, 2023 and was discharged on December 12, 2023. There was a release of information form to a physician that was signed by the client on May 19, 2023; however, the release form did not include the name of the person, agency, or organization to whom the disclosure would be made. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The consent form without the name of the person, agency, or organization to whom the disclosure is made are voided for client # 1 is voided. The consent for #3 the information will be updated in the consent form next time client visits clinic for in-person services. #7 the incomplete consent form will be voided.
Program Director/ supervisor will train the DA counselors about completing a consent to release information in it's entirety before both parties sign on it. DA counselors will also be educated on not signing a document if name of a person, agency, or organization to whom the disclosure is not included. If the document is not applicable to the client, it will be removed. Program Director/ supervisor will assume the responsibility to accomplish this task. |
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 document the specific information to be disclosed on consent to release information forms in seven of seven client records reviewed. Client # 1 was admitted on April 21, 2023 and was still active at the time of the inspection. The release of information forms to a physician and an emergency contact were signed by the client on April 21, 2023, but the release forms did not include the specific information to be disclosed. Client # 2 was admitted on April 24, 2023 and was still active at the time of the inspection. The release of information forms to a physician and an emergency contact were signed by the client on April 24, 2023, but the release forms did not include the specific information to be disclosed. Client # 3 was admitted on April 25, 2023 and was still active at the time of the inspection. The release of information forms to a physician and an emergency contact were signed by the client on April 25, 2023, but the release forms did not include the specific information to be disclosed. Client # 4 was admitted on April 28, 2023 and was discharged on August 4, 2023. The release of information forms to a physician and an emergency contact were signed by the client on April 28, 2023, but the release forms did not include the specific information to be disclosed. Client # 5 was admitted on April 29, 2023 and was discharged on July 17, 2023. The release of information forms to a physician and an emergency contact were signed by the client on April 28, 2023, but the release forms did not include the specific information to be disclosed. Client # 6 was admitted on September 6, 2023 and was discharged on December 1, 2023. The release of information form to an emergency contact was signed by the client on September 6, 2023, but the release form did not include the specific information to be disclosed. Client # 7 was admitted on May 19, 2023 and was discharged on December 12, 2023. The release of information forms to a physician and an emergency contact were signed by the client and witness on April 28, 2023, but the release forms did not include the specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For client #1, #2 and #3, a new form will be used with the specific information to be disclosed within one month of in-person visit. This form will be reviewed by the client and signed. For the client #4, #5, #6 and #7, the consent forms without the specific information to be disclosed will be voided. The consent to release information form will be updated with the recommended changes. The form will include the list of information that client can review and decide what they would like to release. The review and updating of this form will be completed by Program director/ supervisor. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in seven of seven client records reviewed. In each client record reviewed, there was a release of information form to a physician and none of the release forms included the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent to release information for emergency contact will be updated by including the purpose on the ROI to a physician, which is "collaborative care". The updated form will be signed by all 07 clients during their in-person visit within 45 days. The newly updated ROI for physicians will be used with all future clients. |
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 client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 and that no client may be deprived of a civil right solely by reason of treatment in seven of seven client records reviewed.In every client record reviewed, the client rights acknowledgement sign-off form did not include acknowledgement of this specific client right.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In the clients rights form, the acknowledgement that the clients \ have been notified of their right that 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 and that no client may be deprived of a civil right solely by reason of treatment, will be included. This new form will be reviewed and signed by all the existing clients and any new clients in the future. Program director/ supervisor will update the document with this acknowledgement/ information and ensure it is implemented. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of ethnicity in seven of seven client records reviewed.In every client record reviewed, the client rights acknowledgement sign-off form did not include acknowledgement of this specific client right.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of ethnicity will be included in the admission forms. The existing clients will receive the updated form and will have the opportunity to review and sign during their in-person visit in the next 45 days. Program director/ supervisor will ensure this new form will be used for all existing and new clients to avoid the deficiency happening in the future. |
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 client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.In every client record reviewed, the client rights acknowledgement sign-off form did not include acknowledgement of this specific client right.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director will be added to the admission documents. Program director/ supervisor will be in charge of this task. All Intakes/ admission documents are revised and approved by supervisor. The DA supervisor will ensure this deficiency will not reoccur |
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 client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in seven of seven client records reviewed.In every client record reviewed, the client rights acknowledgement sign-off form did not include acknowledgement of this specific client right.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records will be added to admission documents. Program director/ supervisor will be in charge of this task. All Intakes/ admission documents are revised and approved by supervisor. The DA supervisor will ensure this deficiency will not reoccur. Existing clients will have the opportunity to review and sign the updated documents on this matter. |
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 client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.In every client record reviewed, the client rights acknowledgement sign-off form did not include acknowledgement of this specific client right.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records will be added to admission documents. Program director/ supervisor will be in charge of this task. All Intakes/ admission documents are revised and approved by supervisor. The DA supervisor will ensure this deficiency will not reoccur while reviewing the documents. |