INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5 and 6, 2012, 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.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policies and procedures, the project director failed to 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 an assessment of staff training needs.
The findings include:
The facility's policies and procedures were reviewed on December 5, 2012 and December 6, 2012. The policy and procedures presented as the policy and procedures on staff development did not indicate the time frame for completing an assessment of staff training needs.
The findings were confirmed during an interview with the Quality Assurance Specialist on December 6, 2012 at approximately 2:15 P.M.
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Plan of Correction
The Policy and Precedure plan has been updted to include the following practices, effective December 6, 2012:
The employee will review the listed trainings on the "Individual Training Plan" form. After reviewing the form the employee will check off those trainings the employee feels she/ he needs to broaden their knowledge and further their development. After the employee self assesses their own training needs on the Individual training plan form, he/she will meet with their direct supervisor. The employee's direct supervisor and the employee will then review together the employee's self assessment of training needs. During this meeting the supervisor will also assess the employee's training and development needs and document their recommended training on the Individual Training Plan form. The Individual Training Plan and assessment of training needs are reviewed and updated each fiscal year. The supervisor reviews and monitors the Individual Training Plan and Assessment of Training Needs on an ongoing basis and in weekly supervision with the Drug and Alcohol Counselor. Quality Assurance monitors and reviews all staff trainings on a quarterly basis for compliance. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel records, the facility failed to document an assessment of staff training needs.
The findings include:
On December 5, 2012 and December 6, 2012, four personnel records requiring documentation of an assessment of staff training needs were reviewed. The facility did not document an assessment of staff training needs in four of four personnel records reviewed, specifically, personnel records # 1, 2, 3 and 4.
Employee # 1, the project director, was hired on March 14, 2005 and was due to have an assessment of staff training needs. However, personnel record # 1 did not include documentation of an assessment of staff training needs as of December 6, 2012.
Employee # 2, the facility director was hired on November 29, 2010 and was to have an assessment of staff training needs. However, personnel record # 2 did not include documentation of an assessment of staff training needs as of December 6, 2012.
Employee # 3, a counselor, was hired on October 11, 2011 and was to have an assessment of staff training needs. However, personnel record # 3 did not include documentation of an assessment of staff training needs as of December 6, 2012.
Employee # 4, the receptionist/billing clerk was hired on November 1, 2010 and was to have an assessment of staff training needs. However, personnel record # 4 did not include documentation of an assessment of staff training needs as of December 6, 2012.
The findings were discussed with the Quality Assurance Specialist on December 6, 2012 at approximately 2:15 P.M.
This is a repeat citation. The facility was cited on May 23, 2012; January 24, 2012; June 22, 2011; and January 201 for noncompliance with this standard.
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Plan of Correction
On December 10, 2012 all Drug and Alcohol employee files were updated to include an employee assessment of staff training needs. The employee and supervisor will work together to update these assessments each fiscal year. The supervisor will review and monitor employee assessment of training needs in weekly supervision with the employee. Quality Assurance will review and monitor assessment of training needs quarterly for compliance. |
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 and the facility's Staffing Requirements Facility Summary Report Form, the facility failed to develop an individual training plan for an employee the beginning of their training year.
The findings include:
On December 5, 2012, five personnel records requiring documentation of an individual training plan were reviewed. The facility failed document an individual training plan at the beginning of their training year in one of five records reviewed, specifically, personnel record # 1.
Employee # 1, the project director, was hired on March 14, 2005. An individual training plan was due at the beginning of the facility's training year, July 30, 2012. However, the facility did not document an individual training plan for employee # 1 until December 4, 2012.
The findings were confirmed during an interview with the Human Resources Director on December 5, 2012 at approximately 2:00 P.M.
This is a repeat citation. The facility was cited on January 24, 2012; June 22, 2011; and January 20, 2011 for noncompliance with this standard.
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Plan of Correction
Effective December 10, 2012 a procedure has been put into place to address the timely completion of employee #1's individual training. The procedure includes submission of the individual plan to the employee's immediate supervisor on June 1st of each year for review and completion. The supervisor of employee #1 will be given 2 weeks to meet with employee #1 to review and complete the individual training plan. Once the training plan is complete, the document must be submitted to Human Resources for filing. Quality Assurance will review and monitor this process on a quarterly basis for compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff.
The findings include:
On December 5, 2012 and December 6, 2012, two personnel records were reviewed to verify that employees had HIV/AIDS training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received a minimum of 6 clock hours of HIV/AIDS training in one of two personnel records reviewed, specifically, personnel record # 4.
Employee # 4, the receptionist and billing clerk, was hired on November 1, 2010. Employee # 4 would have been due to complete 6 clock hours HIV/AIDS training by November 1, 2012. However, personnel record # 4 did not include documentation of HIV/AIDS training as of December 6, 2012.
The findings were confirmed with the Quality Assurance Specialist on December 6, 2012 at approximately 10:00 A.M.
This is a repeat citation. The facility was cited on May 23, 2012 and January 24, 2012 for noncompliance with this standard.
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Plan of Correction
This employee completed the HIV/AIDS training on April 18, 2011. Though the training certificate was not in the personnel file during the audit, it was confirmed through the training sign-in sheet that this employee completed the HIV/AIDS training. The trainer has been contacted and will submit a replacement training certificate comfirming this employee's completion of tne HIV/AIDS training. We anticipate rectification of this deficiency by the January 7, 2012. At which time we anticipate having the training certificate signed and placed in the employee's personnel file. Quality Assurance will review personnel files quarterly to ensure that trainings are completed within the appropriate time frames and that they are properly documented and recorded. Any deficiencies will be reported to the supervisor for immediate resolution. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on a review of the facility's written procedures for staff and clients to follow in case of an emergency, the facility failed to provide written procedures for staff and clients to follow in case of an emergency for the evacuation and transfer of clients to a safe location for internal disasters for the facility's current location.
The findings include:
The written procedures for staff and clients to follow in case of an emergency were reviewed on December 5, 2012 and December 6, 2012. The policy in the manual addressed a safe location for internal disasters for the facility's previous location. The policy in the manual does not address a safe location for internal disasters for the facility's current location.
The findings were confirmed with the Quality Assurance Specialist on December 6, 2012 at approximately 10:00 A.M.
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Plan of Correction
On December 6, 2012 the Quality Assurance Director made the appropriate correction to the policy and procedure manual to indicate that the safe location for internal disasters is at the 4301 Rising Sun Avenue location. The change was made immediately and is currently recorded in the policy and procedure as of the above date. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the person, agency or organization to whom disclosure is made.
The findings included:
Five client records were reviewed for informed and voluntary consents to release information. The facility failed to document an informed and voluntary consent from the client that included the person, agency or organization to whom disclosure is made in five of five records, records # 1, 2, 3, 4 and 5.
The findings were reviewed and confirmed by the quality assurance staff member, facility director and clinician.
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Plan of Correction
On December 10, 2012 the Drug and Alcohol Intake worker and Counselor were trained by in a group training by the Supervisor and Quality Assurance Director, on the appropriate completion of the informed and voluntary consent form. The five client records are currently being updated to reflect the appropriate information on the informed and voluntary consent during each client's next individual session. To ensure that these forms are completed efficiently, ongoing trainings and direction on the completion of this form will be provided during individual supervision. Quality Assurance will audit all new intake records within 7 days after each intake is completed to ensure compliance and accuracy. |
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 the review of client records, the facility failed to document an informed and voluntary consent from the client that included the purpose of the disclosure in five of five records reviewed.
The findings included:
Nine client records were reviewed. Five client records were reviewed for informed and voluntary consents to release information from the client.
Patient records # 1, 2, 3, 4 and 5 failed to document a consent that included the purpose of the disclosure. All of the records had a consent to release information signed by the client that was missing this content.
The findings were reviewed and confirmed by the quality assurance staff member, facility director and clinician.
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Plan of Correction
On December 10, 2012 the Drug and Alcohol Intake worker and Counselor were trained by in a group training by the Supervisor and Quality Assurance Director, on the appropriate completion of the informed and voluntary consent form. The five client records are currently being updated to reflect the appropriate information on the informed and voluntary consent during each client's next individual session. To ensure that these forms are completed efficiently, ongoing trainings and direction on the completion of this form will be provided during individual supervision. Quality Assurance will audit all new intake records within 7 days after each intake is completed to ensure compliance and accuracy. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records, the facility failed to document a consent to treatment was signed by the client and staff member at intake in five of five records reviewed.
The findings include:
Nine client records were reviewed. Five client records were reviewed for documentation of a signed consent to treatment. Client records # 1, 2, 3, 4 and 5 did not include a consent to treatment signed by the client and staff member upon intake. The records did not include the consent to treatment form at the time of the review.
The findings were reviewed and confirmed by the quality assurance staff member, facility director and clinician.
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Plan of Correction
On December 10, 2012 the Drug and Alcohol Intake worker and the Drug and Alcohol Counselor were trained in a group training by the Supervisor and Quality Assurance Director, on the appropriate completion of the consent to treatment form. The five client records are currently being updated to include the consent to treatment form during each client's next individual session. To ensure that these forms are completed efficiently, ongoing trainings and direction on the completion of this form will be provided during individual supervision. Quality Assurance will audit all new intake records within 7 days after each intake is completed to ensure compliance and accuracy. |
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 that included a composite picture of the client, an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions. Additionally, the facility failed to complete all psychosocial evaluations in accordance with timeframes per facility policy.
The findings include:
Facility policy titled: Psychosocial evaluations states: Psychosocial histories and psychosocial evaluations are to be completed within 30 days of intake.
Five client records requiring psychosocial evaluations were reviewed on December 6, 2012. The facility failed to document a psychosocial evaluation that included a composite picture of the client, an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions in five of five records reviewed, records # 1, 2, 3, 4 and 5. Additionally, the facility failed to complete psychosocial evaluations in accordance with facility policy in one of five records reviewed, record # 1.
Client # 1 was admitted on 10/10/2012. The facility failed to document a psychosocial evaluation that included the client's coping mechanisms, negative factors, and attitude toward treatment. Additionally, the document was not dated so it was not possible to determine if it was completed within 30 days from intake per facility policy.
Client# 2 was admitted on 8/30/2012. The facility failed to document a psychosocial evaluation that included the client's assets and strengths, and coping mechanisms.
Client # 3 was admitted on 9/19/2012. The facility failed to document a psychosocial evaluation that included the client's support systems, coping mechanisms and attitude toward treatment.
Patient # 4 was admitted on 8/15/2012. The facility failed to document a psychosocial evaluation that included the client's assets and strengths, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions/impressions.
Patient # 5 was admitted on 8/7/2012. The facility failed to document a psychosocial evaluation that included the client's problems and needs, assets and strengths, support systems, coping mechanisms, negative factors and attitude toward treatment.
The findings were reviewed and confirmed by the quality assurance staff member, facility director and clinician.
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Plan of Correction
On December 10, 2012, the psychosocial evaluation tool was updated to reflect the elements of the composite picture of the client which includes an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions. On December 10, 2012 the Drug and Alcohol Counselor was provided training, by the Supervisor and Quality Assurance Direcor on how to complete a composite picture of the client that includes an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions. The Drug and Alcohol Counselor was also provided in-service instruction on the appropriate timeframes that each psychosocial evaluation is to be completed. A flow chart has been developed and will be used to track adherence to procedural documentation timelines identified in the policy and procedure manual. The Drug and Alcohol counselor will begin updating all current psychosocial evaluations to include the above mention composite picture elements immediately. This process will occur with each client during individual sessions. This process will be monitored ongoing in supervision and during monthly Quality Assurance chart audits. |
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 treatment plan updates in accordance with facility policy.
The findings include:
Facility policy states: Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days for outpatient and 30 days for intensive outpatient.
Five client records were reviewed for treatment plan updates on December 6, 2012. The facility failed to document treatment plans in accordance with facility policy and/or to include an assessment of progress in five of five records reviewed, # 1, 2, 3, 4 and 5.
Client # 1 was admitted to the outpatient program on 10/10/2012. The treatment plan was updated on 11/1/2012; however, the update failed to include an assessment of the client's progress.
Client # 2 was admitted to the outpatient program on 8/30/2012. The treatment plan was updated on 9/28/2012; however, the update failed to include an assessment of the client's progress. A second treatment plan update was due by 11/28/2012 and was not documented at the time of the review.
Client # 3 was admitted to the outpatient program on 9/19/2012. The treatment plan was updated on 10/18/2012; however, the update failed to include an assessment of the client's progress.
Client # 4 was admitted to the outpatient program on 8/15/2012. The treatment plan was updated on 9/14/2012 and 11/21/2012; however, the treatment plan updates failed to include an assessment of the client's progress.
Client # 5 was admitted to the intensive outpatient program on 8/7/2012. The treatment plan was updated on 9/7/2012, 10/4/2012 and 11/8/2012; however, the treatment plan updates failed to include an assessment of the client's progress.
The findings were reviewed and confirmed by the quality assurance staff member, facility director and clinician.
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Plan of Correction
On December 10, 2012 the Drug and Alcohol Counselor was given in-service training, instruction and guidance on the appropriate timelines for updating Outpatient and Intensive Outpatient Treatment Plans. The Drug and Alcohol will immediately update all treatment plans during upcoming/scheduled individual sessions. A flow chart has been developed and implemented to track the timeliness of documentation completion. The chart provides accountability and color coded reminder notifications to the Drug and Alcohol Counselor, Supervisor and Quality Assurance Director in increments of 10 and 5 days before documents are due. This form is completed on a weekly basis by the Intake Worker and submitted as a report on a weekly basis. The Drug and Alcohol counsleor was also provided in-service training on how to complete the "progress in treatment" section of the treatment plan. The treatment plan was updated to make the "progress in treatment" more apparent on the form. |
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 consultation notes in one of two client records.
The findings include:
Two client records were reviewed for case consultations on December 6, 2012. The facility failed to document a case consultation in one of two records reviewed, record #5.
Client # 5 was admitted to the intensive outpatient program on 8/7/2012. A case consultation was documented on 8/8/2012. A case consultation was scheduled to be completed by 11/8/2012 but was not documented at the time of the review.
The findings were reviewed and confirmed by the quality assurance staff member, facility director and clinician.
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Plan of Correction
On December 10, 2012 the Drug and Alcohol Counselor reviewed the charts for accuracy and compliance in documenting case consultations. During the month of December 2012 all outstanding case consultations will be scheduled with clients and the case consultation team to bring the records into compliance. The Drug and Alcohol Counselor will work with the Supervisior to ensure that case consultations capture the appropriate information and are completed within the guidelines of the treatment process. The flow chart will be utilized as a tracking and management mechanism of this process. The supervisor will review the completion of case consultations in supervision and the Quality Assurance COordinator will review records on a continual basis to measure compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan that included all of the components in two of two client records.
The findings include:
Nine client records were reviewed. Two of the records reviewed were documented as successful discharges. The records were required to have an aftercare plan including goals with time frames, support services, contact person and reentry process. The facility did not document an aftercare plan which included all of the components in client records # 7 and 8.
Client # 7 was admitted to treatment on 3/22/2012 and discharged successfully on 8/20/2012. The aftercare plan was not signed by the client. The discharge summary noted the client accepted aftercare. The aftercare plan did not include goals with time frames, support services, contact person and re-entry process.
Client # 8 was admitted to treatment on 1/26/2012 and discharged successfully on 9/1/2012. The aftercare plan did not include goals with time frames, contact person and re-entry process.
The findings were reviewed and confirmed by the quality assurance staff member, facility director and clinician.
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Plan of Correction
On December 10, 2012 the Supervisor and Quality Assurance Coordinator met with the Drug and Alcohol counselor to review the completion of aftercare planning. The Drug and Alcohol Counsleor was provided with in-service instruction on the proper completion of the document to include goals with time frames, support services, contact person and the reentry process. Accurate completion of this document will be reviewed ongoing in supervison and by the Quality Assurance Coordinator during periodic chart audits. |