INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21-23, 2009 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 August 21, 2009.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's comprehensive staff development program, the facility failed to document an overall plan to address the training needs of staff.
Findings:
The facility's comprehensive staff development program was reviewed on July 21-23, 2009. The facility was required to document an overall training plan to address staff training needs. The facility's annual training plan did not identify the trainers for the scheduled trainings.
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Plan of Correction
On August 19th the Facility Director and VP met to review the requirements of including trainers on the annual staff development program and the 2009-10 training paln has been updated to include this information. The annual training plan is due to be completed by June 30th of each year and the Facility Director will review by June 20th to make sure trainers are included. If they are not included,he will meet with VP to complete the plan. |
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 a review of the facility's comprehensive staff development program, the facility failed to document an annual evaluation of the overall training plan.
Findings:
The facility s comprehensive staff development program was reviewed on July 21-23, 2009. The facility was required to document an annual evaluation of the overall training plan. The documented evaluation of the training plan did not determine the extent to which the plan addressed the identified staff training needs.
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Plan of Correction
The Facility Director and VP met on 7/23/09 after meeting with Licensing Specialist and completed an addendum to the annual evaluation of training plan to document the extent to which the training needs of staff were met. The Facility Director will make sure it is completed by June 30th and will review by the 20th to make sure it is reviewed and that it meets the staff needs. |
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 document individual training plans in five of five personnel records.
Findings:
Six personnel records were reviewed on July 21-23, 2009. An individual training plan was required in five personnel records. The facility did not document individual training plans in December, as stated in the facility's policy manual, in personnel records # 1, 2, 3, 4 and 6.
Personnel record # 1 individual training plan dated 7/16/09
Personnel record # 2 individual training plan dated 11/18/08
Personnel record # 3 individual training plan dated 7/7/09
Personnel record # 4 individual training plan dated 6/9/09
Personnel record # 6 individual training plan dated 6/30/09
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Plan of Correction
The Facility Director will meet with VP to revise the policy so that it will reflect that the individual trainings will be documented by June 30th. The Facility Director will review all the files by May 30th to make sure they are properly developed. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a measurement of the water temperature during the annual onsite licensing inspection, the facility failed to maintain water temperatures at or below 120 Farenheit. in each bathroom.
The findings included:
The water temperature in the bathroom in the D&A suite was measured at 140 degrees Farenheit on July 23, 2009.
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Plan of Correction
A new Mixing Valve was installed on July 27th to regulate the water temperature and has been set at a level to not exceed 120 degrees. The Facility Director monitored for four weeks and found the temperature to be within the proper range. He will conduct once a month random checks. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection during the annual onsite licensing inspection July 21-23, 2009, the facility failed to ensure that no space heaters were present in the building.
The findings included:
During the physical plant inspection of July 21 ,2009, a space heater was observed in the hallway outside the clerical office in the Drug and Alcohol suite.
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Plan of Correction
Heater was removed on 7-21 and the staff was individually reminded of the policy regarding no space heaters. The Facility Director will conduct weekly rounds to make sure there are no portable heaters on the site. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection during the annual onsite licensing inspection July 21-23, 2009, the facility failed to ensure that each set of stairs exceeding two steps had a handrail installed.
The findings included:
During the physical plant inspection of July 21, 2009, Division staff observed that the exit on the third floor had a set of stairs with three steps leading to the outside exit door from that floor. No hand rail was installed on the stairs.
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Plan of Correction
Missing hand rail was installed on July 21st according to regulations. The Facility Director will walk through the building and will look at all locations with stairs to ensure all handrails are probided by 9-15. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection during the annual onsite licensing inspection July 21-23, 2009, the facility failed to ensure that interior exits and stairs were lighted at all times.
The findings included:
During the physical plant inspection of July 21, 2009, the basement was inspected. The front exit from the basement onto the street did not have working lights in that section of the basement to illuminate the stairs.
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Plan of Correction
Light bulb was replaced on 7-21.Facility Director will walk through the site on a weekly basis to make sure all bulbs are functioning and replaced as needed. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of administrative materials, the facility failed to document a performance report summarizing the progress towards meeting the goals and objectives for the 2008-2009 fiscal year.
The findings included:
At the time of the annual inspection the agency administrative materials reviewed and the required materials were requested from the compliance officer. No report of progress towards meeting goals and objectives was documented for the 2008-09 fiscal year.
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Plan of Correction
The Facility Director and VP will meet by 9-30 to complete a report for FY08-09. This report was developed and lost due to a computer problem. The hardware in question was not connected to the organization's server. All computers are tied to the server at this point. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative materials, including the annual audit, during the annual onsite licensing inspection of July 21-23, 2009, the facility failed to ensure that the audit was completed at the end of the fiscal year.
The findings included:
The agency audit for fiscal year 2007-08 was reviewed. The fiscal year ends on June 30 annually. The audit was not completed until February 13, 2009.
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Plan of Correction
The Project Director will meet with the VP, the Facility Director and CFO to revise the timeline for completing the audit to make sure audit is completed within six months of fiscal year.The Vp will meet monitor on a monthly basis following the end of fiscal year. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the review of the agency policy and procedure manual during the annual onsite licensing inspection of July 21-23, 3009, the facility failed to document a written procedure which complied with 4 Pa. Code subsection 255.5.
The findings included :
The facility confidentiality policy and procedures were reviewed. The policy and procedure documented was not written in accordance with applicable confidentiality law/regulation as specified below:
The policy and procedure on page 43 of the manual fails to identify client identifying information as any information written or verbal that would identify a person as a participant in substance abuse treatment and/or as any information that would identify a person as a "drug abuser" or a "drug dependent person", [71 P. S. Subsection 1690.102(b); 71 P. S. Subsection 1690.108(b); and 42 CFR Part 2, Subpart B, Subsection 2.11]. The policy and procedures erroneously state that "...a client record is defined as all written clinical information, observations, reports or fiscal documents relating to prospective, current or former clients when the creation or retention of these documented is either required or authorized as part of the operations..." and further states that, "...This policy does not apply to documents or patient - identifying information that were public before the client entered treatment ... even if they are now part of the clinical record (55 Pa. Code subsection 5100.31(h)...". The policy and procedure fails to include 55 Pa. Code Subsection 5100.37 regarding drug and alcohol treatment information.
The facility fails to address and define employees who may have access to client identifying information and limiting those employees to those who have duties that arise out of the provision of drug and alcohol treatment, the diagnosis for the need for drug and alcohol treatment and the referral for drug and alcohol treatment, [42 CFR Part 2, Subpart B, Subsection 2.12(c)(3)]. On page 46, section 9a of the policy and procedure manual the facility states that, "...All counselors , intake workers , nurses, physicians, administrators and clerical personnel have access to client records...". APM is a large, multi-service organization serving the needs of a diverse community in the North Philadelphia area. Some staff employed by APM as "...counselors, intake workers, nurses, physicians, administrators and clerical personnel...", who do not have duties that arise out of the provision of drug and alcohol treatment, the diagnosis for the need for drug and alcohol treatment and the referral for drug and alcohol treatment. Further, Page 57 of the policy and procedure manual regarding the Remote Access Policy, states "... APM will allow a limited number of users the right to access the computer system from remote locations". The policy fails to identify the employees, by job title, who will be permitted access to the D&A client records.
Facility policy and procedure on page 58 of the manual - Use of Portable Storage Devices - states: "Handheld devices such as Palm Pilots , Blackberry RIM's, PDA/Cell phone combinations and Pocket PC's are increasingly used by APM staff members. All staff members who use PDA's to record protected health information(PHI) are required to follow reasonable safeguards to protect the confidentiality of the data ...". The policy and procedure fails to address the security of this information and allows the information to leave the facility recorded on the personal property of employees. This does not meet the requirements at 28 Pa. Code Subsection 709.28(b) - "The project shall secure client records within locked storage containers." The facility cannot know that this information is maintained in a virtual locked storage container when the device is the personal property of employees.
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Plan of Correction
Facility Director will review the confidentiality regulations with staff by September 15th. Facility Director will monitor compliance by reviewing the release of information on a weekly basis after the meeting for 3 months.Project Director, VP, and Facility Director will meet and review the 4 Pa. Code subsection and each section of the findings as written and revise the facility's current policy and procedure to adhere to 4 Pa. code section 255.5 by September 25th. The Project Director will submitt policy revisions for Board approval by October 31st and will place in policy Manual. Policy will be discussed with staff in staff meeting. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a review of the agency policy and procedure manual and a physical plant inspection, the facility failed to properly store all drug and alcohol client records in a locked storage container.
The findings included:
During the physical plant inspection conducted on the morning of July 21, 2009, the closed client records located in the basement of the facility were in file cabinets which were not secured with locks.
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Plan of Correction
The facility is in the process of purchasing a devise (bar locks)to lock the cabinets. If we are not able to purchase one that will work the agency will buy new cabinets with locks by Sept 15th. In the interum,a second lock has been placed on the basement door and the only staff members having access to keys are the Facility Director and the VP.No one will be permitted into the basement until the file cabinets are properly secured including any workmen unless accompanied by the Facility Director. |
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 shall 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 during the annual onsite licensing inspection of July 21-23, 2009, the facility failed to document the specific information to be disclosed on written consent to release information forms and also failed to comply with the restrictions imposed at 4 Pa. Code subsection 255.5(b) in three of twelve client records.
The findings included:
Twelve client records were reviewed on July 22 and 23, 2009. The mental health portion of client records # 10 and 12 included documentation of written consents to release information where the information was to be released to government officials or insurance entities. The consent's to release information did not list the specific information that would be released to these entities, but the general release was to include information that identified the individual as a participant in drug and alcohol treatment. Client record # 8 included documentation of a consent to release information which permitted the release of laboratory urinalysis results to probation officers. The limitations imposed at 4 Pa. Code Subsection 255.5(b) only permit the facility to release information about whether or not the client had relapsed.
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Plan of Correction
Facility Director will meet with staff and will review confidentiality regulations and ensure that the information been released is documented and to whom it has been released to. Meeting will be held on 9-10. Facility Director will review on a weekly basis for 4 weeks and then randomly on a quarterly basis. |
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 shall 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 during the annual onsite licensing inspection July 21-23, 2009, the facility failed to document the purpose for disclosure of the specified information which complied with the requirements specified at 4 Pa. Code subsection 255.5(b).
The findings included:
Twelve client records were reviewed on July 22 and 23, 2009. The purpose for the release of information was not documented on the consent to release information forms documented in client records # 1, 2, 3, 4, 5, 7, 8, 9, 10 and 12.
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Plan of Correction
Facility Director will review the confidentiality regulations with staff on 9-10 and discussed the requirements for including the purpose of the release. Facility Director will review the charts for 4 weeks and randomly thereafter. |
709.31(a) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Department's UDCS.
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Observations
Based on a review of client records during the annual onsite licensing inspection July 21-23, 2009, the facility failed to document the required CIS information in each client record.
The findings included:
During the annual inspection, twelve client records were reviewed. Based on interviews with the an analyst who was present at the review, and the clinical records, it was determined that the facility is program funded and, as a result, was required to document CIS forms in each client record. Additionally, agency policy stated, ".. Administrative assistant transmits the client's relevant information to the state's database, The Client Information System..." No CIS documentation was on file in any of the twelve records reviewed. ( #1, 2,3, 4, 5, 6, 7, 8, 9, 10, 11, 12). Facility staff were not able to produce any documentation demonstrating compliance with this requirement.
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Plan of Correction
Starting 8-28 the billing clerk will maintain the CIS system and the Facility Director will meet with her weekly for two months to ensure that all information is entered into the system. |
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, the facility failed to document a drug and alcohol history in six of nine client records.
Findings:
Twelve client records were reviewed on July 21-23. Drug and alcohol histories were reviewed in nine client records. The facility did not document a drug and alcohol history in client records # 1, 2, 6, 7, 8 and 9.
Client records # 1, 2, 6 and 9 did not document a drug and alcohol history to include the substances most frequently abused and the lengths and patterns of use.
Client record # 8 did not document a drug and alcohol history to include the lengths and patterns of use and the client's perception of the drugs' effect on his/her social, physical and mental state.
Client record # 7 - The client was admitted to the facility on 3/12/09 and discharged on 7/2/09, but a drug and alcohol history was not documented at the time of inspection, July 21 - 23, 2009.
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Plan of Correction
The Facility Director will review with the staff on 9-8 the importance and time frame of documenting complete drug and alcohol history for all clients.The Facility Director will review on a weekly basis for two months and randomly on a quaterly basis thereafter. |
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, the facility failed to document a personal history in six of nine client records.
Findings:
Twelve client records were reviewed on July 21-23. Personal histories were reviewed in nine client records. The facility did not document a personal history in client records # 3, 6, 7, 8 and 9.
Client record # 3 did not include documentation of a personal history to include the client's legal and employment/vocational history.
Client record # 6 did not include documentation of a personal history to include the client's family, legal, employment/vocational and educational history.
Client records # 8 and 9 did not include documentation of a personal history to include the client's family, legal and educational history.
Client record # 7 - The client was admitted to the facility on 3/12/09 and discharged on 7/2/09, but a personal history was not documented at the time of inspection on July 23, 2009.
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Plan of Correction
The Facility Director will review with the staff on 9-8 the importance and time frame of documenting complete personal history for all clients.The Facility Director will review on a weekly basis for two months and randomly on a quaterly basis thereafter. |
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 a review of client records, the facility failed to document a psychosocial evaluation in five of nine client records.
Findings:
Twelve client records were reviewed on July 21-23, 2009. Psychosocial evaluations were reviewed in nine client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4 and 7.
In client records # 1, 2, 3 and 4 the client's assets/strengths, support systems, coping mechanisms and attitude towards treatment were identical from record to record.
Client record # 7 includes documentation that the client was admitted to the facility on 3/12/09 and discharged on 7/2/09, but a psychosocial evaluation was not documented at the time of inspection on July 23, 2009.
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Plan of Correction
The Facility Director will review with the staff on 9-8 the importance and time frame for documenting a complete psychosocial evaluation for all clients.The Facility Director will review on a weekly basis for two months and randomly on a quaterly basis thereafter. |
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 a review of client records, the facility failed to document a treatment plan update in four of five client records.
Findings:
Twelve client records were reviewed on July 21-23, 2009. A treatment plan update was required in five client records. The facility did not document a treatment plan update to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 4, 5 and 6.
Additionally, client record # 3 includes documentation that the client was admitted to the facility on 4/6/09, and the treatment plan was dated 5/6/09, but a treatment plan update was not documented at the time of inspection on July 23, 2009.
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Plan of Correction
The Facility Director will review with the staff on 9-8-2009 the importance and time frame for completing treatment plan updates and including progress in relationship to the stated goals on prior treatment plans for all clients. The Facility Director will review on a weekly basis for two months and randomly on a quaterly basis thereafter. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in five of eight client records.
Findings:
Twelve client records were reviewed on July 21-23, 2009. A case consultation was required in eight client records. The facility did not document a case consultation in client records # 1, 3, 4, 5 and 7.
In client records # 1, 4 and 5 the summary and the disposition sections of the case consultations were identical from record to record.
Client record # 3 includes documentation that the client was admitted to the facility on 4/6/09, but a case consultation was not documented at the time of inspection.
Client record # 7 includes documentation that the client was admitted to the facility on 3/12/09 and discharged on 7/2/09, but a case consultation was not documented at the time of inspection.
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Plan of Correction
The Facility Director will review with the staff on 9-8-2009 the importance and time frame for documenting case consultations for all clients. The Facility Director will review on a weekly basis for two months and randomly on a quaterly basis thereafter. |