INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection to the initial on-site licensure inspection conducted on January 12 - 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
The follow-up inspection was conducted on July 6, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site follow-up 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 August, 2010.
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Plan of Correction
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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 March 2010 through June 2010. During that time it was noted that fire drills were conducted only in the mornings. The clinical supervisor was interviewed on 7/6/2010 and confirmed that fire drills were only conducted in the morning.
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Plan of Correction
The Clinical Supervisor will conduct unannounced fire drills during the mornings, afternoons and evening hours of clinic operations. These fire drills will be documented using the fire drill logs that are maintained at the clinic. This ongoing procedure will be monitored by the Clinical Supervisor. |
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 administrative materials presented at the inspection and an interview with the facility director on July 6, 2010, the facility failed to make an annual report available to the public for the 2008-2009 fiscal year which ended June 30, 2009 and the 2009- 2010 fiscal year which ended on June 30, 2010. The facility is publicly funded.
The findings included:
The annual reports were completed; however the facility could not provide documentation as to how the reports were made public. The facility director confirmed that they did not have supporting documentation.
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Plan of Correction
APM's Communications Manager is working with APM's IT department to create a link to APM's annual reports for FY 2008 and 2009. The annual reports will be added to the website using a PDF program. The link will be available on the main page of APM's website. The number of visits to the annual report link will be quantified on a daily basis using a program that calculations visits to the link. The Communications Manager and the IT department will monitor the website and the link on a continuous basis to ensure that they are both working properly. The link will become active not later than
January 1, 2011. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a medical history for client # 1.
The findings include:
The facility policy title 'Biopsychosocial Assessment' states:
The biopsychosocial assessment is one of the main foundations for a good comprehensive treatment plan and must be completed within 30 days of admission by the counselor assigned to the case.
A good biopsychosocial assessment includes the following elements:
Reflects all identified presenting problems.
Gathers information on past and present aspects of the physical, psychiatric, emotional, educational, maturational, spiritual, nutritional, vocational, legal, sexual and social elements of the client ' s life, as well as a comprehensive medical history, including current and past medications, medical treatments the client may be receiving, current medical condition, and food, environmental and drug allergies.
A comprehensive substance abuse history.
Six client records were reviewed during the onsite licensing inspection on July 6, 2010.
Three records required documentation of a medical history.
Three records were still in the intake phase and were not due for completion of the medical history.
The facility failed to document a medical history for client record # 1.
Client # 1 was admitted to the program on 5/3/10.
The medical history is due within 30 days.
The client's last day of counseling was 6/30/10.
At the time of review on 7/6/10 the facility failed to document a medical history.
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Plan of Correction
The substance abuse counselor will be be given instruction on the proper documentation and other procedures associated with completing the biopsychosocial assessment. Specific instruction on the timelines associated with completing the biopsychosocial assessment will be addressed in weekly supervision. The Quality Assurance Coordinator will provide inservice instruction on the comprehensive completion of the biopsychosocial assessment focusing on gathering information on the medical history. The inservice instruction will be conducted beginning August 2, 2010 and will be on-going. The comprehensive and timely completion of the biopsychosocial will be monitored in weekly supervision by the Clinical Supervisor. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a drug or alcohol history for client # 1.
The findings include:
The facility policy titled ' Biopsychosocial Assessment' states:
The biopsychosocial assessment is one of the main foundations for a good comprehensive treatment plan and must be completed within 30 days of admission by the counselor assigned to the case.
A good biopsychosocial assessment includes the following elements:
Reflects all identified presenting problems.
Gathers information on past and present aspects of the physical, psychiatric, emotional, educational, maturational, spiritual, nutritional, vocational, legal, sexual and social elements of the client ' s life, as well as a comprehensive medical history, including current and past medications, medical treatments the client may be receiving, current medical condition, and food, environmental and drug allergies.
A comprehensive substance abuse history.
Six client records were reviewed on July 6, 2010.
Three records required documentation of the client's drug or alcohol history, client record # 1 failed to document a drug or alcohol history.
Three records were still in the intake phase and were not yet due for the drug or alcohol history.
Client # 1 was admitted to the program on 5/3/10.
The drug or alcohol history is due within 30 days per facility policy.
The client's last day of counseling was 6/30/10.
At the time of review on 7/6/10 the facility failed to document a drug or alcohol history.
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Plan of Correction
The substance abuse counselor will be be given instruction on the proper documentation and other procedures associated with completing the biopsychosocial assessment. The intake process and the timelines associated with completing the biopsychosocial assessment will be addressed in weekly supervision. The Quality Assurance Coordinator will provide inservice instruction on the comprehensive completion of the biopsychosocial assessment with particular attention being paid to documentation of the drug and alcohol history. The inservice instruction will be conducted beginning August 2, 2010 and will be on-going. The Quality Assurance Coordinator will conduct clinical chart audits on a weekly basis to assess the accuracy of the clinical documentation and provide summary reports to the Clinical Supervisor. The comprehensive and timely completion of the biopsychosocial will be monitored in weekly supervision by the Clinical Supervisor on an on-going basis. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records and the facility's policy and procedures, the facility failed to document a personal history for client # 1.
The findings include:
The facility policy titled ' Biopsychosocial Assessment' states:
The biopsychosocial assessment is one of the main foundations for a good comprehensive treatment plan and must be completed within 30 days of admission by the counselor assigned to the case.
A good biopsychosocial assessment includes the following elements:
Reflects all identified presenting problems.
Gathers information on past and present aspects of the physical, psychiatric, emotional, educational, maturational, spiritual, nutritional, vocational, legal, sexual and social elements of the client ' s life, as well as a comprehensive medical history, including current and past medications, medical treatments the client may be receiving, current medical condition, and food, environmental and drug allergies.
A comprehensive substance abuse history.
Six client records were reviewed on July 6, 2010.
Three records required documentation of the client's personal history, client record # 1 failed to document a personal history.
Three records were still in the intake phase and were not yet due for the personal history.
Client # 1 was admitted to the program on 5/3/10.
The personal history is due within 30 days per facility policy.
The client's last day of counseling was 6/30/10.
At the time of review on 7/6/10 the facility failed to document a personal history.
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Plan of Correction
The substance abuse counselor will be be given instruction on the proper documentation and other procedures associated with completing the biopsychosocial assessment. The intake process and the timelines associated with completing the biopsychosocial assessment will be addressed in weekly supervision. The Quality Assurance Coordinator will provide inservice instruction on the comprehensive completion of the biopsychosocial assessment with particular attention being paid to documentation of the personal history. The inservice instruction will be conducted beginning August 2, 2010 and will be on-going. The Quality Assurance Coordinator will conduct clinical chart audits on a weekly basis to assess the accuracy of the clinical documentation and provide summary reports to the Clinical Supervisor. The comprehensive and timely completion of the biopsychosocial will be monitored in weekly supervision by the Clinical Supervisor on an on-going basis. |
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 and the facilities policy and procedure, the facility failed to document psychosocial evaluations in accordance with their policy and procedures.
The findings included:
The facility policy titled 'Biopsychosocial Assessment' states:
The biopsychosocial assessment is one of the main foundations for a good comprehensive treatment plan and must be completed within 30 days of admission by the counselor assigned to the case.
A good biopsychosocial assessment includes the following elements:
Reflects all identified presenting problems.
Gathers information on past and present aspects of the physical, psychiatric, emotional, educational, maturational, spiritual, nutritional, vocational, legal, sexual and social elements of the client ' s life, as well as a comprehensive medical history, including current and past medications, medical treatments the client may be receiving, current medical condition, and food, environmental and drug allergies.
A comprehensive substance abuse history.
The client ' s strengths and the barriers for treatment.
The client ' s goals for treatment.
A mental status exam.
Client ' s history and current risk for aggression, abuse, and suicidally, to determine potential to harm self or others.
Information on the client ' s support system.
The DSM-IV five axis diagnosis.
Is legible.
Includes specific recommendations for biological, social, and psychological interventions that include the details of when, where, and who will execute the recommendations.
Identifies the scope and duration of interventions to be provided.
Suggests proposed type of support services/referrals for physical (e.g., drug interventions with behavior), psychological, social, child welfare, and economic (e.g., public assistance) issues.
The biopsychosocial must contain a summary and evaluation of client ' s condition. The biopsychosocial summary and evaluation must be reviewed and signed by the licensed supervising clinician or Clinical Director
Six client records were reviewed on July 6, 2010.
Three records were required to document a psychosocial evaluation.
Three records were still in the intake phase and were not due for a psychosocial evaluation.
Client # 1 was admitted on 5/3/10.
The facility failed to indicate the completion date and include the counselor's conclusions/impressions.
In addition, the components of the psychosocial evaluation were minimum.
Client # 2 was admitted on 3/4/10, and the psychosocial evaluation was documented on 3/15/10; however, the facility failed to include the counselor's conclusions/impressions; and the components that pertained to assets/strengths, support systems, coping mechanisms, and negative factors were minimum.
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Plan of Correction
The substance abuse counselor will be be given instruction gathering the information in the biopsychosocial assessment. The Quality Assurance Coordinator will provide inservice instruction on the comprehensive completion of the biopsychosocial assessment with particular attention being paid to documenting the completion date, the inclusion of the counselor's conclusions/impressions and the detailed documentation of the psychosocial evaluation, assests/strengths, support systems, coping mechanisms and negative factors. The inservice instruction will be conducted beginning August 2, 2010 and will be on-going. The Quality Assurance Coordinator will conduct clinical chart audits on a weekly basis to assess the accuracy of the clinical documentation and provide summary reports to the Clinical Supervisor. The comprehensive and timely completion of the biopsychosocial assessment will be monitored in weekly supervision by the Clinical Supervisor on an on-going 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 client records, the facility's policy and procedures, and an interview with the facility director, the facility failed to document an individual treatment and rehabilitation plan within 30 days.
The findings include:
The facility's policy titled 'Comprehensive Treatment Plan and Rehabilitation Services' states:
The Comprehensive Treatment plan must be individually tailored to the unique needs of the client, based on psychosocial history, evaluations, assessments, especially of strengths and goals, and on the project and community resources.
The Counselor will formulate the Comprehensive Treatment Plan, which will direct the course of treatment with the client. The Comprehensive Treatment Plan must be completed, legible, documented and in action no later than 30 days after the Intake.
Six client records were reviewed on July 6, 2010.
Three client records required documentation of a complete individual treatment and rehabilitation plan within 30 days.
Three records were in the intake phase and were not due for an individual treatment and rehabilitation plan.
The facility failed to document an individual treatment and rehabilitation plan in client record # 1.
Client # 1 was admitted to the program on 5/3/10 and a preliminary treatment plan was documented on 5/3/10.
The facility failed to document a comprehensive treatment plan at the time of review on 7/6/10 for client # 1.
Client # 1 was listed as an active client at the time of review.
An interview was conducted with the facility director on 7/6/10 and he stated that comprehensive treatment plans are to be completed within 30 days.
He also stated that client # 1 was an active client and that a comprehensive treatment plan was not documented for this client.
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Plan of Correction
The timelines associated with the development of a comprehensive treatment plan will be addressed in weekly supervision by the Facility Director. Weekly supervision will be conducted on an on-going basis to monitor the progress in this area. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan update in 60 days.
The findings include:
The facility's policy titled 'Comprehensive Treatment Plan and Rehabilitation Services' states:
The Counselor must review, update and modify as necessary, the treatment plan at least every 60 days or sooner if the circumstances merit an earlier review. The Counselor may change a client ' s treatment plan at any time, should the goals and objectives be deemed inappropriate and or unnecessary for any clinical reason. The Counselor has the responsibility to coordinate updates and document modifications and the participation of the members of the team, including the client, if necessary.
These updates will review and assess the client's progress in relation to the stated goals of the Comprehensive Treatment Plan.
Six client records were reviewed on July 6, 2010.
One client record required documentation of a treatment and rehabilitation plan update every 60 days.
Five records were not due for the 60 day treatment and rehabilitation plan update.
The facility failed to document an individual treatment and rehabilitation plan update in client record # 2.
Client # 2 was admitted to the program on 3/4/10 and a comprehensive treatment plan was documented on 3/29/10.
At the time of review on 7/6/10 the facility failed to document a treatment plan update.
The treatment plan update should have been documented on 5/29/10.
Client # 2 is listed as an active client.
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Plan of Correction
The timelines associated with the development of an individual treatment plan a rehabilitation plan and a treatment plan update will be addressed in weekly supervision by the Facility Director. Weekly supervision will be conducted on an on-going basis to monitor the progress in this area. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to provide counseling services according to the preliminary or comprehensive treatment plan.
The findings include:
Six client records were reviewed on July 6, 2010.
Three client records were required to document a treatment plan and provide counseling services according to the prescribed plan.
The facility failed to provide counseling services as prescribed in the treatment plans in client records # 2 and 3.
Client # 2 was admitted to the program on 3/4/10 and the comprehensive treatment plan was documented on 3/29/10.
The comprehensive treatment plan prescribed the client individual sessions - once a week and group sessions - once a week.
The record of service lists group sessions on 5/4/10, 4/6/10, 3/16/10, and 3/9/10.
The record of service lists individual sessions on 3/29/10, 3/15/10, 3/8/10, and 3/4/10.
Client # 2 is listed as an active client, and 5/4/10 was the last date that the facility documented interaction with the client, there was no further engagement.
Client # 3 was admitted to the program on 6/14/10 and the preliminary treatment plan was documented on 6/14/10.
The preliminary treatment plan prescribed the client individual sessions - once a week and group sessions - twice a week.
The record of service documents the client as only being seen on 6/14/10.
Client # 3 is listed as an active client, and 6/14/10 was the only date that the facility documented interaction with the client.
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Plan of Correction
The substance abuse counselor will be supervised on the appropriate documentation of services as they are perscribed on both the preliminary and comprehensive treatment plans. The substance abuse counselor will be provided with guidance on how to engage clients who may not be compliant with the perscribed services. The Facility Director will be available to assess situations associated with service availability to determine if modifications are needed to accomodate the clients. Supervision will be provided on an on-going basis. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on the review of client records, the facility failed to provide counseling services on a regular and scheduled basis.
The findings include:
Six client records were reviewed on July 6, 2010.
All records reviewed were required to provide clients with regular and scheduled counseling services.
The facility failed to document in the record of service or progress notes regular and scheduled counseling sessions for client # 2 and 3.
Client # 2 was admitted to the program on 3/4/10 and the comprehensive treatment plan was documented on 3/29/10.
The comprehensive treatment plan prescribed the client individual sessions - once a week and group sessions - once a week.
The record of service lists group sessions on 5/4/10, 4/6/10, 3/16/10, and 3/9/10.
The record of service lists individual sessions on 3/29/10, 3/15/10, 3/8/10, and 3/4/10.
Client # 2 is listed as an active client, and 5/4/10 was the last date that the facility documented interaction with the client, there was no further engagement.
Client # 3 was admitted to the program on 6/14/10 and the preliminary treatment plan was documented on 6/14/10.
The preliminary treatment plan prescribed the client individual sessions - once a week and group sessions - twice a week.
The record of service documents the client as only being seen on 6/14/10.
Client # 3 is listed as an active client, and 6/14/10 was the only date that the facility documented interaction with the client.
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Plan of Correction
The substance abuse counselor will be supervised on the appropriate documentation of services using the progress notes and record of service. This instruction will be include documentation of services as they are perscribed on both the preliminary and comprehensive treatment plans. The substance abuse counselor will be provided with guidance on how to engage clients who may not be compliant with the perscribed services. The Facility Director will be available to assess situations associated with service availability to determine if modifications are needed to accomodate the clients schedules and other needs. Supervision will be provided on an on-going basis. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and a review of the facility's policy and procedures, the facility failed to document a discharge summary in two of six client records reviewed.
The findings include:
The facility's policy titled 'Discharge Policy and Planning, Including Aftercare':
Involuntary Discharge
Clients who do not show for appointments within one-month period, and have no adequate justification for that, are considered AWOL and will be discharged from the program. The referral source must be notified of this involuntary discharge, the date and the reasons for it.
Discharge Summary
The discharge summary is the document most often sent out of the project to referral agencies and must be comprehensive, concise, and completed within one week after discharge, to provide accurate discharge status to aftercare providers - Proyecto Nueva Vida or others - in a timely manner. If the client returns to treatment, the summary will serve as a quick review of his or her record while in Proyecto Nueva Vida. The discharge summary should state what progress, if any, was made on the goals and objectives in the treatment plan
Six client records were reviewed on July 6, 2010.
Three client records were required to document a discharge summary.
Three clients records were active and not required to document a discharge summary.
The facility failed to document a discharge summary in client records # 2, and 3.
Client # 2 was admitted to the program on 3/4/10.
Client # 2 is listed as an active client; however 5/4/10 was the last date that the facility documented interaction with the client, there was no further engagement, therefore a discharge summary should have been documented.
The record of service lists group sessions on 5/4/10, 4/6/10, 3/16/10, and 3/9/10.
The record of service lists individual sessions on 3/29/10, 3/15/10, 3/8/10, and 3/4/10.
Client # 3 was admitted to the program on 6/14/10.
Client # 3 is listed as an active client; however 6/14/10 was the last date that the facility documented interaction with the client, there was no further engagement, therefore a discharge summary should have been documented.
The record of service documents the client as only being seen on 6/14/10.
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Plan of Correction
The substance abuse counselor will be given instruction on the Discharge Policy and Planning, including Aftercare planning. This instruction will be addressed in supervision with the Facility Director. Supervision will be conducted on an on-going basis to monitor progress in this area. |