INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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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 the Staffing Requirements Facility Summary Report and personnel files, the facility failed to document a written individual training plan, with input from the employee and the supervisor, in three of five personnel records reviewed.
Employee #3 was hired as the medical doctor on February 25, 2019. There was no training plan documented, in the record, for the current training year.
Employee #4 was hired as a receptionist on April 4, 2021. There was no training plan documented, in the record, for the current training year.
Employee # 5 was hired as a receptionist on August 30, 2021. There was no training plan documented, in the record, for the current training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning February 1, 2022. APM's QA Assistant will complete a quarterly review of our Behavioral Health staff's training plans, including those of new hires to 1) ensure they are up to date, and 2) note progress made toward Training Plan goals. APM's QA Assistant will then send a report to both the clinical supervisors / facility directors and APM's VP Health and Homeless Services / Project Director. Plans will then be reviewed at the end of each calendar quarter.
APM's VP Health will ensure the Medical Director's Training Plan is updated by February 1, 2022.
The Facility Director will ensure Facility staff training plans are current and in place by February 1, 2022. |
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 and personnel files, the facility failed to ensure that the project director obtained at least 12 clock hours of training for the January 2021 through December 2021 training year.
Employee #1 was hired as the project director on July 1, 2020. There was only 9.5 hours of annual trainings documented for the reviewed training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
APM's Project Director (VP Health and Homeless Services) will develop a Training Plan and submit it to his supervisor, APM's COO, as part of his Annual Performance Review by February 1, 2022. APM's Project Director will then complete at least 12 hours of relevant training by December 31, 2022. APM's COO will then ensure the Project Director submits his Annual Training Plan by December 31 of each year as a part of his Performance Review process. |
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, conducted at approximately 1:00 pm, the facility failed to ensure that all heater units were permanently mounted or installed as there was a space heater located in the Doctor's office.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The portable heater has been removed from the office and will not be replaced. The Facility Director will ensure the building's thermostats are set to a comfortable temperature to facilitate compliance / prevent a recurrence. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel files the facility failed to ensure that the personnel files contained documentation of an annual written individual performance evaluation of which shall be reviewed and signed by the employee in one of three employee records reviewed.
Employee # 1 was hired as the project director on July 1, 2020. There was no documentation that the annual written individual performance evaluation was completed for the review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
APM's COO, the Project Director's supervisor, will complete the Project Director's Annual Performance Evaluation by March 31, 2022 and annually by December 31 thereafter. |
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 must 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, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven of seven client records reviewed.
Client # 1 was admitted on May 19, 2021 and was discharged on January 5, 2022. The consent to release information form to the funding source, signed and dated by the client on May 19, 2021, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
Client # 2 was admitted on June 28, 2021 and was discharged on December 29, 2021. The consent to release information form to the funding source, signed and dated by the client on June 28, 2021, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
Client # 3 was admitted on December 21, 2020 and was discharged on December 22, 2021. The consent to release information form to the funding source, signed and dated by the client on December 21, 2020, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
Client # 4 was admitted on June 19, 2019 and was discharged on August 30, 2021. The consent to release information form to the funding source, signed and dated by the client on June 19, 2019, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
Client # 5 was admitted on June 30, 2021 and was discharged on December 27, 2021. The consent to release information form to the funding source, signed and dated by the client on June 30, 2021, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
Client #6 was admitted June 2, 2021 and was discharged December 27, 2021. The consent to release information form to the funding source, signed and dated by the client on June 2, 2021, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
Client #7 was admitted March 29, 2019 and was discharged June 17, 2021. The consent to release information form to the funding source, signed and dated by the client on March 29, 2019, had a section labeled "and/or" for the information to be disclosed; however, the form did not include what specific information was to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the February 2021 licensing inspection
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Plan of Correction
APM's Consent to Release Information forms were updated in our intake packets to be compliant with 4 Pa. Code 255.5 (b) by December 31, 2020. The charts where the deficiencies were found were discharges who were admitted before the updates. APM's Counselors will review Consents to ensure they are current in their next Treatment Planning session with active program participants, beginning February 1, 2022 and update them, as necessary. Facility Directors will review participant files to ensure compliance. |
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 ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of seven client records reviewed.
Client #3 was admitted December 21, 2020 and was discharged December 22, 2021. A treatment plan update was completed on April 16, 2021 and the next update was due no later than June 16, 2021. However, the treatment plan update was not completed until July 8, 2021. Additionally, the next treatment plan update was due no later than September 8, 2021. However, the treatment plan update was not completed prior to discharge.
Client #4 was admitted June 19, 2019 and was discharged August 30, 2021. A treatment plan update was completed on March 24, 2021 and the next update was due no later than May 24, 2021. However, the treatment plan update was not completed prior to discharge.
Client #6 was admitted June 2, 2021 and was discharged December 27, 2021. A treatment plan update was completed on September 10, 2021 and the next update was due no later than November 10, 2021. However, the treatment plan update was not completed prior to discharge.
Client #7 was admitted March 29, 2019 and was discharged June 17, 2021. A treatment plan update was completed on April 10, 2021 and the next update was due no later than June 10, 2021. However, the treatment plan update was not completed prior to discharge.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
PM Counselors will review and renew Treatment Plans every 60 days. When they are having difficulty engaging a participant to come in and do the Treatment Plan, they will update the Treatment Plan as follows: "The client is currently resistant to engagement and has not appeared to update the Treatment Plan. In their absence, we will continue to implement their most recent Treatment Plan and redo the Treatment Plan when they are reengaged." This change will go into effect February 1, 2022 and compliance will be ensured by the Project Director during their monthly review of Treatment Plans. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of one applicable record reviewed.
Client #7 was admitted March 29, 2019 and was discharged June 17, 2021. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the February 26, 2021 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
APM Counselors will follow up with discharged participants by telephone one month after discharge beginning February 1, 2022 and record the attempt and any conversation that may ensue in a non-billable note which will be available in Credible. Facility Directors will ensure compliance by reviewing Discharged Cases when they review Treatment Plans on a monthly basis.
APM's Counselor will follow up with Client #7 by February 1, 2022. |