INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2nd and 3rd, 2019 of Asociacion De Puertorriquenos En Marcha Proyecto Nueva Vida by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for facility directors in employee #2's employee record.
Employee #2 was hired as facility director on April 2, 2015 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2017 through June 30, 2018. Employee #2's employee record did not document any training hours for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective February 1, 2019 all employee files will be monitored monthly by the VP of Health, Clinical Director, Clinical Supervisor and Quality Assurance to ensure that trainings are up to date and meet the 704.11 training regulations. The VP of Health, Clinical Director and Clinical Supervisors will use email and supervision sessions to share training opportunities, recommend appropriate trainings and measure competencies learned in training. This monitoring protocol is ongoing and will remain in effect as part of the clinic's continuous quality improvement process. |
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
A review of the January 2018 through December 2018 fire drill logs was conducted during the onsite inspection. The facility failed to conduct an unannounced drill during September 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective February 1, 2019 the Director of Business Management, Facilities Manager and Quality Assurance will implement a monthly fire drill schedule. The schedule will be maintained by the Director of Business Management and monitored by Quality Assurance and the VP of Health to ensure that barriers are addressed quickly and effectively. Monthly fire drill schedules are implemented as part of the clinic's standard operating practice and will be monitored monthly and quarterly by Quality Assurance for it's efficiency. |
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 seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including retaining civil rights and liberties except as provided by statute.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 4 2019 Quality Assurance will change the Substance Use policy and procedure manual to include documentation of all the required client rights language, including the section about retaining civil rights and liberties except as provided by statute. This policy change will also will be added made on the client forms.
The updated Substance Use clinic policy and procedure manual and the client's rights forms will be reviewed by the VP of Health to confirm that all of the required documentation is present in the manual and on the client's rights forms.
On February 11, 2019 the updated client's rights forms will be given to every client in the clinic during sessions with the Substance Use Counselor Assistant. The Substance Use Counselor Assistant will explain the form to the client with particular focus on the changes. The client will be asked to sign the updated form and will be offered a copy of the signed form. A signed copy of the updated form will be added to the client permanent record.
This process will be reviewed quarterly and ongoing by Quality Assurance and the VP of Health to ensure compliance standards are met. |
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 seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including may not discriminate based on ethnicity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 4 2019 Quality Assurance will change the Substance Use policy and procedure manual to include documentation of all the required client rights language, including the section about retaining civil rights and liberties except as provided by statute. This policy change will also include the addition of the word ethnicity to the client's rights forms.
The updated Substance Use clinic policy and procedure manual and the client's rights forms will be reviewed by the VP of Health to confirm that all of the required documentation is present in the manual and on the client's rights forms.
On February 11, 2019 the updated client's rights forms will be given to every client in the clinic during sessions with the Substance Use Counselor Assistant. The Substance Use Counselor Assistant will explain the form to the client with particular focus on the changes. The client will be asked to sign the updated form and will be offered a copy of the signed form. A signed copy of the updated form will be added to the client permanent record.
This process will be reviewed quarterly and ongoing by Quality Assurance and the VP of Health to ensure compliance standards are met.
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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 seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 11 2019 Quality Assurance will change the Substance Use policy and procedure manual to include documentation to add the in regards to the client having the right to submit rebuttal data or memoranda to their own records. We will also include the language about retaining civil rights and liberties except as provided by statute. This policy change will also will be added made on the client forms.
The updated Substance Use clinic policy and procedure manual and the client's rights forms will be reviewed by the VP of Health to confirm that all of the required documentation is present in the manual and on the client's rights forms.
Beginning February 18, 2019 the updated client's rights forms will be given to every client in the clinic during sessions with the Substance Use Counselor Assistant. The Substance Use Counselor Assistant will explain the form to the client with particular focus on the changes. The client will be asked to sign the updated form and will be offered a copy of the signed form. A signed copy of the updated form will be added to the client permanent record.
This process will be reviewed quarterly and ongoing by Quality Assurance and the VP of Health to ensure compliance standards are met.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.
Client #1 was admitted on July 27, 2017 and was still active at the time of the inspection. A treatment plan update was completed on August 30, 2018 and the next update was due no later than October 29, 2018; however, the next documented treatment plan update was dated December 3, 2018.
Client #4 was admitted on September 24, 2018 and was still active at the time of the inspection. A treatment plan was completed on September 24, 2018 and the next update was due no later than November 23, 2018; however, the next documented treatment plan update was dated December 6, 2018.
Client #5 was admitted on July 11, 2018 and was still active at the time of the inspection. A treatment plan update was completed on September 17, 2018 and the next update was due no later than November 16, 2018; however, the next documented treatment plan update was dated December 5, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning February 4, 2019 the Substance Use Counseling staff will be provided in-service training and instruction on the timelines associated with completing treatment plans within the 704 guidelines.
The Clinical Director will facilitate the quarterly and ongoing trainings. The Clinical Supervisor will review treatment planning competency in monthly supervision sessions, and as needed, with each Substance Use Counseling staff person.
The Clinical Director and Quality Assurance will conduct monthly and ongoing chart reviews to monitor progress in this area. Quality Assurance and the Clinical Director will submit reports on chart review outcomes to the VP of Health and Clinical Supervisor.
The Clinical Supervisor will conduct case reviews in monthly supervision, (and as needed), to address deficiencies documented in reports from Quality Assurance and the Clinical Director. The Clinical Supervisor will work with the Substance Use staff on corrective action plans, trainings and performance improvement initiatives.
These procedures are an ongoing part of our continuous quality improvement initiative and performance development. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
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Plan of Correction
APM has ordered a sign that will be affixed to the exterior wall of the clinic. The External Affairs Director has placed the order. The sign will provide information on the services provided, the office hours and days of the week and who to contact in case of emergency.
The sign is scheduled to arrive by February 18, 2019 and is designed to withstand the weather. Once the sign arrives the Facilities Director will ensure that sign is posted in a place that is visible to the general public and that the sign is in English and Spanish.
Quality Assurance and the VP of Health will monitor this process and ensure that the task is completed promptly. |