INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12-14, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on February 10, 2010.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of administrative training documentation and supplementary folders presented at the licensing inspection and interviews with the facility staff, the facility failed to document the required annual evaluation of the 2008-2009 annual training plan.
The findings include:
On 1/ 13/2010, facility training documentation and training reports were reviewed. The materials presented failed to include documentation of an evaluation of the training plan for the 2008-2009 training year which commenced on July 1, 2008 and ended on June 30, 2009. The clinical supervisor and administrative staff were interviewed on 1/13/2010 at approximately 11 A.M. The staff were under the impression that they had addressed the required components in the documentation presented . The content of the information presented failed to document evaluative comments about whether the plan addressed the identified needs of the 08-09 training year, including a determination of the extent to which implementing the plan eliminated or satisfied the identified needs.
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Plan of Correction
An evaluation of each training facilitated will be submitted to the Project Director by the trainee. The Project Director will develop a quantified report of this information to see trends, consistencies/inconsistencies and the overall effectiveness of the trainings facilitated. The results of these reports will be reviewed at the monthly Quality Assurance meeting where feedback from the Quality Assurance Committee will direct the course of future trainings. The information gathered will be compiled and presented on the annual training evaluation. This process will begin at the next Quality Assurance meeting scheduled for February 24, 2010. The Quailty Assurance Coordinator will oversee this system of checks and balances to ensure that annual training evaluation is completed yearly and accurately. |
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.
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Observations
Based on the review of the agency fire drill log , the facility failed to document the use of alternate exits during fire drills.
The findings include:
Fire drills were reviewed for the period from 08/09 through 12/09. Fire drill documentation for each fire drill stated that front and rear exits were used for each fire drill. The documentation did not specify exits on which floor and did not make any indication that exits were alternated for each fire drill.
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Plan of Correction
Project Director will assure the usage of alternate exits during fire drills. The Project Director will provide onsite fire drill trainings with all facility staff. During these trainings alternate exits and alternate floors will be emphasized. The trainings will begin on February 24, 2010. There will be three trainings during this week, Monday, Wednesday and Friday to ensure that all staff members have the opportunity to participate in the fire drill trainings. The week of March 1, 2010 the Project will conduct unaccounced Fire Drills utilizing alternate exit and floor routes. The trainings and unannounced fire drills will be overseen and documented appropriately by the Project Director. |
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
Based on the review of the fire drill log and an interview with the clinical supervisor, the facility failed to document that fire drills were conducted at different times of the day.
The findings include:
Fire drill documentation was reviewed for the period extending from August 2009 through December 2009. During that time it was noted that fire drills were conducted only in the afternoons. The clinical supervisor was interviewed on 1/12/2010 and indicated that fire drills were conducted in the afternoons because there were fewer clients present and it made the fire drills more manageable.
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Plan of Correction
The Project Director will assure the performance of Fire Drills at different times of the day. The Project director will conduct unannounced fire drills during varying times of the day. In trainings that will begin on February 22, 2010 staff will be given instruction on the appropriate procedures to use when there are small numbers of clients present as well as when there are larger numbers of clients present in the clinic. In this way the Project Director can ensure that all facility staff persons are skilled to meet the task. The Project Director will oversee all unannounced Fire Drills, review the outcome and make adjustments as is assessed necessary. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the facility policy and procedure and administrative materials presented at the inspection, the facility failed to make an annual report available to the public for the 2008-2009 fiscal year which ended June 30, 2009. The facility is publicly funded.
The findings included:
Facility policy and procedure was reviewed on January 12 and 13, 2010. Documentation in the manual contained only the 2007-2008 annual report. No documentation of the annual report for 2008-2009 was presented. The fiscal year ended on June 30, 2009. The report is required at the end of each fiscal year. Staff were interviewed on January 13, 2010 and reported that they were under the impression that the extension granted for the annual audit included an extension for the annual report. The Facility Director confirmed that the annual report for the fiscal year ended June 30, 2009 had not been completed.
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Plan of Correction
The Vice President of Health, The Vice President of Finance and The Communications Manager are working together to complete the annual report and make it avalable to the public for the 2008-2009 fiscal year. The anticipated complition date is March 31th, 2010. During the month of January, a timeline for the coordination of the annual report will be developed by VP of Health and VP of Finance with the CEO to ensure that this doesn't happen again. The timeline will be monitored by the Program Director along with the Communications Manager. |
709.26(a)(8) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(8) Disciplinary actions.
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Observations
Based on the review of facility policy and procedure and the personnel handbook and interviews with administrative staff, the facility failed to document a policy and procedure which addressed progressive discipline.
The findings include:
Facility policy and procedure relative to personnel policy and procedure was reviewed by Division staff on January 12 and 13, 2010. At that time, no documentation of a progressive discipline policy and procedure was observed. In interviews with facility staff on January 13 and 14, 2010, the administrative staff including the CFO and the Project Director indicated that, on the advice of their attorneys, they did not include a progressive discipline policy and procedure because such an inclusion would adversely impact the agency's not for profit status. Facility staff confirmed that no such policy was in place.
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Plan of Correction
The Vice President of Health and The Director of Human Resources are working together to develop a Policy and Procedure which addresses progressive discipline. The completion date anticipated is March 31, 2010. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records during the licensing inspection, the facility failed to document an informed and voluntary consent for each release of client identifying information in nine of nine client records.
The findings include:
Division staff reviewed eleven client records. Each of the client records reviewed was required to have a signed consent to release information form for each release of client identifying information. Nine client records were eligible for funding from monies administered through the Medical Assistance funding stream . Information was entered into the Eligibility Verification System \ operated by the Department of Public Welfare (DPW) for determining eligibility for funding through this funding stream, prior to obtaining the client's written consent to release information to the Department of Public Welfare. The information entered into the EVS system identifies the client as a participant in drug and alcohol treatment. This system required entering client identifying information in order to obtain a determination as to the client's eligibility. Information was released without the client's written consent.
Client record # 1 was admitted on 10/22/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 2 was admitted on 10/13/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 3 was admitted on 10/16/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 4 was admitted on 8 /14/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 5 was admitted on 9/3/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 6 was admitted on 9/28/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 7 was admitted on 10/14/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 8 was admitted on 11/30/09. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
Client record # 11 was admitted on 1/5/10. Client identifying information was entered into EVS to determine eligibility. No consent to release information to DPW was documented in the client record.
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Plan of Correction
The Project Director with the support of the Quality Assurance Coordinator developed an informed voluntary consent form for each release of client identifying information. These form will be used during the intake process to gain permission from the potential client to access the Eligibility Verification System in determination of eligibility for funding through this funding stream. The form was implemented on Januray 27th, 2010. The use of this form will be monitored on a weekly basis by the Project Director. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records during the inspection, the facility failed to document psychosocial evaluations which addressed possible relationships, conditions and causes leading to the client's current situation in ten of ten client records.
The findings included:
Eleven client records were reviewed at the time of the inspection. Ten of these were required to have documentation of a psychosocial evaluation that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. One record was still in the intake phase and was not applicable for this standard.
Client record # 1 was admitted on 10/22/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 2 was admitted on 10/13/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 3 was admitted on 10/16/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 4 was admitted on 8/14/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 5 was admitted on 9/3/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 6 was admitted on 9/28/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 7 was admitted on 10/14/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 8 was admitted on 11/30/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 9 was admitted on 10/23/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
Client record # 10 was admitted on 12/2/09. The facility failed to document a psychosocial evaluation which identified possible relationships, conditions and causes leading to the client's current situation as of 1/14/2010.
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Plan of Correction
The biopsychocial is in the process of being revised by the Project Director and The Quality Assurance Coordinator. It is anticipated that the biopsychosocial revision will be completed by March 31st, 2010. Training will be scheduled for the week of April 1st, 2010, tentatively, and facilitated by the Quality Assurance coordinator ongoing until all staff is trained. The revised biopsychosocial will comprehensively gather information that addresses possible relationships, conditions and causes leading to the client's current situation along with other information pertinent to treatment. The Project Director will monitor clinical documentation in a weekly supervision on an ongoing basis. |