INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 21-23, 2009 licensure renewal inspection. The follow-up inspection was conducted on November 4-5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite 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 November 30, 2009.
|
Plan of Correction
|
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.
|
Observations
At time of the follow-up review on 11/4/09, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the annual audit of financial activities was not yet due to be completed. The Facility must resubmit the original plan of correction.
|
Plan of Correction
Project Director will meet with Medical Director,Facility Director and Vice President for Finance and Administration to revise the timeline for completing the audit to make sure audit is completed within six months of fiscal year. The Medical Director will monitor on a monthly basis following the end of the fiscal year |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based on a tour of the facility's physical plant, the facility failed to properly store all drug and alcohol client records in a locked storage container.
The findings included:
A physical plant tour was conducted on November 5, 2009 at approximately 1:00 PM. The record storage room was locked, but the room was not used solely for the purpose of record storage. The room contained items that did not pertain to record storage.
|
Plan of Correction
The Project Director will facilitate the removal of all items and materials that do not pertain to record storage and will monitor on a weekly basis to maintain the area clear of any other materials.
Date of completion: 11/06/09
|
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.
|
Observations
Based on the review of client records, the facility failed to document the purpose for disclosure of the specified information which complied with the requirements specified in 4 Pa. Code subsection 255.5(b).
The findings include:
Ten client records were reviewed on November 4-5, 2009. Of those ten, the purpose for the release of information was reviewable in four client records. The facility did not document the purpose for the release of client information on the signed consent forms in client records # 4, 5, 6 and 7.
Client record # 4 documented a signed consent to release client information to " Housing Department APM " , but the release did not document the purpose for releasing the client's information.
Client record # 5 documented a signed consent to release client information to " Abriendo Camino Housing " , but the release did not document the purpose for releasing the client's information.
Client record # 6 documented a signed consent to release client information to a parole agent, but the release did not document the purpose for releasing the client's information.
Client record # 7 documented a signed consent to release client information to " Pan American Clinic " , but the release did not document the purpose for releasing the client's information.
|
Plan of Correction
The Project Director will facilitate training on the proper completion of the confidential release form in accordance with APM policy and procedures and 4 Pa. Code Subsection 255.5(b). The Project Director will facilitate and monitor the development of forms wherein the disclosure of specified information for housing and parole officers and collaborative care agencies are prewritten. Project Director will conduct weekly supervision with clinical staff to monitor progress in this area. Target completion date for procedure implementation December 21, 2009 |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
|
Observations
Based on a review of facility documentation and a review of client records, the facility failed to demonstrate a data collection and record keeping system that allows for the efficient retrieval of data as needed.
The findings include:
During the plan of correction follow up inspection completed on November 4-5, 2009, the facility was unable to efficiently retrieve the information requested by the licensing specialist.
The licensing specialist requested a list of active client records on November 4, 2009. The facility director provided a list that included both active and discharged client records. An actual review of the client records was the only way to determine which records were active. The facility director stated the list had not been updated recently.
On November 5, 2009 at approximately 11:15 AM, two additional client records were requested by the licensing specialist for review. The facility director did not make these records available until approximately 12:30 PM.
|
Plan of Correction
Project Director will facilitate the development of a system wherein active and discharged clients are updated daily by counselors and receptionist and monitored and reviewed weekly by the Project Director. Project Director will facilitate the development of a report system wherein clinical staff will provide a daily report of admissions and discharges. Active client records will be complied and maintained separately from discharge client records. Target completion date for procedure implementation November 16, 2009 |
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.
|
Observations
Based on the review of client records, the facility failed to document a complete personal history in four of four client records.
The findings include:
Ten client records were reviewed on November 4-5, 2009. Of those ten client records, personal histories were reviewable in four client records. The facility did not document a complete personal history in client records # 5, 6, 9 and 10.
Client record # 5 was admitted to the facility on 9/28/09, but a personal history was not documented at the time of inspection on November 4, 2009. The facility's 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. "
Client record # 6 did not include documentation of a personal history to include the client's legal and employment/vocational history.
Client record # 9 did not include documentation of a personal history to include the client's employment/vocational and educational history.
Client record # 10 did not include documentation of a personal history to include the client's educational history.
|
Plan of Correction
The Quality Assurance Coordinator will further audit clinical documentation and provide training to counselors on areas of deficiency. Project Director will conduct weekly supervision with clinical staff to monitor progress in this area. Training was conducted with all clinical staff regarding these and other areas on November 13, 2009. On going training is conducted biweekly. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in three of four client records.
The findings include:
Ten client records were reviewed on November 4-5, 2009. Of those ten client records, psychosocial evaluations were reviewable in four client records. The facility did not document a complete psychosocial evaluation in client records # 5, 9 and 10.
Client record # 5 was admitted to the facility on 9/28/09, but a complete psychosocial evaluation was not documented at the time of inspection on November 4, 2009. The facility's 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. "
Client records # 9 and 10 did not document a psychosocial evaluation to include the client's needs or problems that can or cannot be resolved through the treatment process or that might inhibit treatment.
Client records # 9 and 10 did not document a psychosocial evaluation to include the client's negative factors that might affect treatment.
|
Plan of Correction
The Quality Assurance Coordinator will further audit clinical documentation and provide training to counselors on areas of deficiency. Project Director will conduct weekly supervision with clinical staff to monitor progress in this area. Training was conducted with all clinical staff regarding these and other areas on November 13, 2009. On going training is conducted biweekly. |
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.
|
Observations
Based on the review of client records, the facility failed to document a complete treatment plan update in two of three client records.
The findings include:
Ten client records were reviewed on November 4-5, 2009. Of those ten client records, a treatment plan update was required in three client records. The facility did not document a complete treatment plan update in client records # 2 and 3.
In client record # 2, a treatment plan update was documented on 10/20/09, but this treatment plan update did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Client record # 3 was admitted to the facility on 7/24/09, and the treatment plan was documented on 8/24/09, but a treatment plan update was not documented at the time of inspection on November 4, 2009.
|
Plan of Correction
The Quality Assurance Coordinator will facilitate training on APM's treatment plan update policy that indicates that treatment plans updated no later than every 60 days, and how to document progress in treatment based on the Comprehensive Treatment Plan. Project Director will conduct weekly supervision with clinical staff to monitor progress in this area.
Date completed on 11/06/09 and will continue by biweekly training review.
|
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.
|
Observations
Based on the review of client records, the facility failed to document an individualized case consultation in three of three client records.
The findings include:
Ten client records were reviewed on November 4-5, 2009. Of those ten client records, case consultations were required in three records. The facility did not document an individualized case consultation in client records # 1, 2 and 3.
Client records # 1, 2 and 3 each had a case consultation dated October 23, 2009. The summary and the disposition sections of these cases consultations were identical from record to record.
|
Plan of Correction
The Quality Assurance Coordinator will facilitate training on APM's policy on case consultation.
Project Director and Quality Assurance Coordinator will revise the form as necessary to make more useful on 11/13/09.
Project Director will conduct weekly supervision with clinical staff to monitor progress in this area beginning on 11/16/09
|