INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18, 2011 through January 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Asociacion De Puetorriquenos 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 February 20, 2011.
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Plan of Correction
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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 the review of personnel records and an interview with director, the facility failed to document assessments of staff training needs in one of three records reviewed.
The findings include:
Six personnel records were reviewed on January 18, 2011 and January 19, 2011. Assessment of staff training needs was required in three of four personnel records, #1, 2 and 3. Per the facility's policy and procedure manual, the assessment of staff training needs are to be completed at the end of the facility ' s fiscal year which was June 30, 2010. An interview with the director confirmed that this was not done in employee record #1.
Employee record #1 was hired March 15, 2005 and the assessment of staff training needs was to be completed by the end of the facility's fiscal year June 30, 2010. As of January 19, 2011 an assessment of staff training needs for employee #1 was not documented.
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Plan of Correction
As of January 24, 2011 all assessments of all Proyecto Nueva Vida staff training needs has been completed. The Directors of both Human Resources and Proyecto Nueva Vida has implemented a collaborative effort with the Information Technology (IT) department where a reminder that yearly staff training updates are due. The system is connected to APM's electronic system and is set to generate a reminder email to the Directors of Human Resources and Proyecto Nueva Vida two weeks before the due date of each evaluation of each employee. The thinking behind the 2 week notification is because our agency requires a two week notice for all requests for time off. In this way we have reasonable time for preparation. The email informs the directors of the date of the previous evaluation, the name of the employee and the upcoming due date of the next evaluation. This same email is also sent to the Facility Director as a back up. In this way late completion of yearly reviews can be avoided. The electronic generated reminders will go into effect on March 1, 2011. The process and procedure will be monitored by the Deputy Vice President of Health in weekly supervision. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records and an interview with director, the facility failed to document feedback forms on trainings in three of four records reviewed.
The findings include:
Six personnel records were reviewed on January 18, 2011 and January 19, 2011. Feedback forms were required in four of four personnel records, #1, 2, 3 and 4. Per the facility' s policy and procedure manual, feedback forms are to be completed after every training. An interview with the director confirmed that this was not done in employee records, #1, 2 and 3. Training certificates were reviewed for training year starting July 1, 2009 and ending June 30, 2010.
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Plan of Correction
All training feedback forms have been updated. A procedure that includes the completing and submitting the training feedback form with the training certificate. Staff turn all training certificates in to Human Resources. Human Resources and the Facility Director have instituted a policy ensures that when the training certificate is turned in the feedback form will be completed. This procedure is effective immediately. Adhereance to this policy will be monitored monthly by the Human Resources Director and the Facility Director. |
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 the review of personnel records and an interview with director, the facility failed to document individual training plan in one of three records reviewed.
The findings include:
Six personnel records were reviewed on January 18, 2011 and January 19, 2011. Individual training plans were required in three of four personnel records, #1, 2 and 3. Per the facility's policy and procedure manual, individual training plans are to be completed at the end of the facility's fiscal year which was June 30, 2010. Employee record #1 was hired March 15, 2005 and their individual training plan was to be completed by the end of the facility's fiscal year June 30, 2010. As of January 20, 2011 the individual training plan for employee #1 was not documented in the employee's record.
An interview with the director confirmed that a training plan was not completed for employee #1.
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Plan of Correction
As of January 24, 2011 all assessments of all Proyecto Nueva Vida staff individual training plans has been completed. The Directors of both Human Resources and Proyect Nueva Vida have implemented a collaborative effort with the Information Technology (IT) department to generate a reminder that yearly staff individual training plan updates are due. The system is connected to APM's electronic system and is set to generate a reminder email to the Directors of Human Resources and Proyecto Nueva Vida two weeks before the due date of each training plan of each employee. The thinking behind the 2 week notification is because our agency requires a two week notification for all requests for time off. In this way we have reasonable time for preparation. The email informs the directors of the date of the previous training plan, the name of the employee and the upcoming due date for the next training plan. This same email is also sent to the Facility Director as a back up. In this way late completion of yearly reviews can be avoided. The electronic generated reminders will go into effect on March 1, 2011. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records and an interview with the director, the facility failed to provide sufficient number of staff who had CPR and first aid training during the project's hours of operation.
The findings include:
The facility's current hours are Monday through Friday 8:30 am to 8 PM and Saturday 9 am to 3 pm. This was documented in the facility's policy and procedure manual and also posted on the front door of the office building. At this present time only two staff on the drug and alcohol area of the building has a current CPR/First Aid certification and three on staff on the mental health area of the building has a current CPR/First Aid. After reviewing the time sheets it was determined that the facility did not have sufficient CPR/First Aid coverage due to times that those particular staff was not working. An interview with the director's confirmed that they did not have sufficient CPR/First Aid coverage.
Also, the facility has a van driver who was hired November 1, 2010 and at this present time does not have their CPR/First Aid certification. The facility has a van driver to provide services for patiens needing transportation to treatment. An interview with the director's confirmed that the van driver did not have their CPR/First Aid certification.
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Plan of Correction
APM is working to schedule an agency wide CPR/First Aid training at the 4301 Rising Sun Avenue site. The training is anticipated to be conducted no later than May 2011. All staff, including support staff have been instructed that CPR/First Aid is required. Information regarding independent completion of the training was provided to both the Mental Health Clinic and the Drug and Alcohol clinic staff on January 24, 2011. This information provides information on outside agencies that offer CPR/First Aid training. APM anticipates that more than 50% of its staff located at 4301 Rising Sun Avenue will be CPR/First Aid certified by May 2011. The support van driver service has been suspended pending the completion of the appropriate certifications and trainings. All treatment service participants who were utilizing the van service are provided tokens as a supplement until the van service can be re-instated. Re-instatement is anticipated for May 2011. |
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 personnel records and an interview with the director, the facility failed to ensure and document that the project director completed at least 12 hours of training for the 2009/2010 training year in one of two personnel records.
The findings include:
Six personnel records were reviewed on January 18, 2011 through January 19, 2011. One employee record represented the project director who was required to have obtained 12 hours of training for the 2009/2010 training year based on the hire date, #1. A review of the employee record revealed documentation of only seven hours of training.
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Plan of Correction
The Project Director has been scheduled for 12 hours of training for the fiscal year 2011/2012. A system has been put in place as of January 31, 2011 that will ensure the Project Director, along with other APM direct care staff, acquires the required hours of training for each fiscal year. APM has established a Annual Training Series Event. This event consists of all the trainings required by the Department of the State. They consist of 9 training topics and add up to more than 25 hours of training. They will be begin in March of each year and be completed by June 15th of each year. In this way APM can ensure that required trainings are completed within a specific timeframe each year ensuring accountable and tracking. |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a licensing inspection and a discussion with the director, the facility failed to have maintained all structures on the grounds of the facility so as to be free from any danger to health and safety.
The findings include:
During the introduction of the licensing inspection on January 18, 2011, in the President ' s conference room, it was observed that there was a leak in the ceiling of the conference room. During the two days of inspection, January 18, 2011 and January 19, 2011, the spot on the ceiling tile grew due to the continuous leak from the roof of the facility. An interview with the directors and maintenance confirmed that there was a leak.
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Plan of Correction
The leak in the roof was repaired on January 24, 2011. The roof has since been inspected and confirmed to be in stable condition. The Maintainence Supervisor is responsible for repairs to the facility. The Facility Director will monitor the condition of the facility in monthly meetings with the Maintenance Supervisor. The first monthly meeting will be conducted on the third Wednesday of March and will be continuous on the third Wednesday of each month. In this way the status of the facility can be monitored and repairs can be addressed more expediently. If deficiencies are identified in the absence of the monthly maintenance meetings, reports will be submitted to the maintenance supervisor within 24 hours. |
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a licensing inspection and a discussion with the director, the facility failed to have noncombustible covered containers that prevent the penetration of insect and rodents.
The findings include:
At the time of the licensing specialist's departure from the facility on January 18, 2011, it was observed that the dumpster was not covered. Also, the dumpster was observed to be full with additional trash bags located outside of the dumpster. A discussion was conducted with the directors on January 19, 2011, informing them of what had been observed on January 18, 2011.
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Plan of Correction
The dumpster has been cleaned of all debris on the ground surrounding the dumpster. After further investigation it was found that the dumpster was placed close to the fence and the covers were behind the dumpster so that they could not be closed. Steps taken since this inspection was that the dumpster was moved away from the fence to reposition the cover. The cover was placed over the opening of the dumpster and the dumpster moved back against the fence in a secure fashion. We are currently assessing our need for an extra trash collection day or the purchase of a second dumpster to offset the increase in trash accumulation we are experiencing. We anticipate that decisions will be made in this area no later than March 2011. The Maintenance Supervisor is responsible for securing the proper storage of trash. The Facility Director and the Maintenance Supervisor will address issues surrounding trash disposal and proper storage during monthly meetings scheduled for the third Wednesday of each month - beginning March 2011. Maintenance will check the storage and disposal of trash each day at the close of busniess to ensure that there is no displaced trash and the dumpster is properly secured and closed. |
705.23 (4) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(4) Locate counseling areas so that noise does not disturb or interfere with counseling sessions.
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Observations
Based on the tour of the facility and an interview with the directors, the facility failed to ensure that noise does not disturb or interfere with counseling sessions.
The findings include:
The physical plant tour took place on January 19, 2011 at around 9:10 am. During the tour of the counselor's office and group room, it was observed that conversations in the next office could be overheard from the group room. An interview with the facility director confirmed this and stated that the facility did not have sound machines to muffle the sounds.
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Plan of Correction
To address this deficiency APM will purchase sound machines to muffle the sounds that can be heard between offices. These machines will be put into place no later than March 2011. The Facility Director has secured the purchase of these machines as of February 14, 2011 by submitting a check request for their purchase to the procurement department. Upon receipt of the sound machines, the Facility Director will facilitate the proper placement of these machines in therapeutic offices and group rooms. The Facility Director will check on the functioning of these machines with the Drug and Alcohol Counselor by conducting listening experiments with staff to measure how sound travels with the machines in place. Adjustments will be made as necessary. The Drug and Alcohol Counselor will monitor the sound machines daily and report any deficiencies to the Facility Director immediately. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the tour of the facility and an interview with the directors, the facility failed to have an exhaust or window for ventilation in the male and female restrooms.
The findings include:
The physical plant tour took place on January 19, 2011 at around 9:10 am. During the tour of the facility it was observed in both the male and female restrooms, at around 9:25 am, did not have any windows or a working exhaust fans for ventilation. An interview with the directors and maintenance confirmed that the exhaust fans in both restrooms were not working.
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Plan of Correction
Both male and female rest rooms have working exhaust/ventilation fans. The fans were inspected by our maintenance crew on January 20, 2011. The exhaust/ventilation fans were repaired and in full working condition by the close of business January 20, 2011. The procedure for reporting deficiencies during daily operations will be reiterated to staff during weekly supervision. Any facility deficiencies that are observed between the monthly scheduled meetings will be reported within 24 hours of its observation. The Facility Director and the Maintenance Supervisor will participate in monthly meetings on the third Wednesday of each month beginning March 2011. During these meetings any facility deficiencies will be reported and the status of outstanding repairs will be reported on providing timelines and any obstacles that need to be addressed. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill record and an interview with the directors, the facility failed to conduct fire drills on different staffing shifts.
The findings include:
The fire drill logs were reviewed on January 18, 2011. The facility's hours of operation were posted on the front door of the facility with the following hours: Monday through Friday 8:30 am through 8 pm and Saturday 9 am to 3 pm. Fire drills were not conducted during the evening shifts for the months of July 2010, August 2010, September 2010, October 2010, November 2010 and December 2010. The latest a fire drill was conducted was in December 2010 at 3pm. An interview with the directors confirmed that there had been no fire drills during the evening hours.
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Plan of Correction
Proyecto Nueva Vida has worked with the maintainence staff and the Mental Health Clinic, that operates in the same building, to schedule combined fire drills during the hours between 5pm and 8pm. These fire drills will begin March 2011 and will be a regular part of Proyecto Nueva Vida operations. These fire drills will utilize the various entrances/exits of the facility and the various hours during evening operations. The fire drills will be overseen and documented by the Director of Proyecto Nueva Vida at the time of each fire drill. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the policy and procedure manual and an interview with the director, the facility failed to make available to the public an annual report.
The Findings Include:
The policy and procedure manual was reviewed on January 18, 2011. The 2009/2010 annual report was to be made to the public by the end of the facility's fiscal year June 30, 2010. During the inspection, the only report that was presented for review was the 2008/2009 annual report which would have been reviewed during the prior inspection. An interview was conducted with the director and she informed me that the 2009/2010 annual report had not been completed.
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Plan of Correction
The Deput Vice President of Human Services, The Vice President of Finance and The Communications Manager are working together to complete the annual report and make it avalable to the public for the 2009-2010 fiscal year. The anticipated completion date is March 31th, 2010. A timeline for the coordination of the annual report will be developed by Deputy Vice President of Human Services and Vice President of Finance with the CEO. During our Monthly Senior Management meetings these timelines will be emphasized and reports required from the finance department to ensure that the adapted timelines are adhered to. The timeline will be monitored by the President of Finance and the Project Director. |
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 the facility's policy and procedure manual and an interview with the director, the facility failed to document the facility's annual audit by the end of the facility's fiscal year which was June 30, 2010.
The findings include:
The policy and procedure manual was reviewed on January 18, 2011. The annual audit was not made available during the inspection. The documentation was required to be made available prior to the end of their 2010 fiscal year which ended June 30, 2010. An interview was conducted with the director and she informed me that the 2009/2010 annual audit was not completed.
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Plan of Correction
Project Director will meet with the Deputy Vice President of Health, Facility Director, Vice President of Finance and Administration to revise the timeline for completing the audit to make sure audit is completed within six months of each fiscal year. The Deputy Vice President of Health will monitor, on a monthly basis, progress in this area. The President of Finance will facilitate the submission of an extension from the proper authorities as we address and retify this deficiency. |
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 psychosocial evaluations in six of eight rehabilitation client records.
The finding includes:
Eight client records were reviewed on January 19, 2011. Psychosocial evaluations were to be documented in six rehabilitation client records, #1, 2, 3, 4, 6 and 7.
Client records #1, 2, 3, 6 and 7 failed to document the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record # 4 did not have documentation of client's psychosocial evaluation. Per the policy and procedure manual, psychosocial evaluations will be completed within 30 days of the client's admit date. Client was admitted on December 7, 2010 and their psychosocial evaluation was to be completed by January 7, 2011.
An interview was conducted with the facility director and he confirmed this was not being done.
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Plan of Correction
The Facility Director will conduct training and supervision weekly with the Drug and Alcohol counselor to address this deficiency. Instruction will be provided on how to indentify assests/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment. Instruction will also be provided on clinical documentation to ensure clinical accuracy in documentation. Instruction will be provided in weekly supervision on the policy's surrounding the completion of the biopsychosocial. Chart audits will be conducted by the Facility Director on all current charts by March 2011 and the procedure of auditing all new admissions charts within 7 days of the new admission. The correction of this deficiency will be monitored weekly by the Deputy Vice President of Human Services. |
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 and a review with the project director and facility director, the facility failed to document follow-up information in two of four discharge records reviewed.
The findings include:
Eight client records reviewed on January 19, 2011. Follow-up information was required in all four of the discharge client records reviewed, # 5, 6, 7 and 8. Per the facility's policy and procedure, clients being referred will be provided follow-up with-in 7 days of the appointment. An interview was conducted with the facility director and it was confirmed that it was not documented in two of the four discharged client records.
Client #5 was admitted on October 18, 2010 and discharged on November 5, 2010 to a higher level of care and as of the date of the inspection there was no documentation of the client's follow-up information in record reviewed.
Client #6 was admitted on July 29, 2010 and discharged on November 11, 2010 and as of the date of the inspection there was no documentation of the client's follow-up information in record reviewed.
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Plan of Correction
The Facility Director has begun a series of instruction in weekly supervision on follow-up with treatment participants. The Facility Director has begun the process of re-engaging clients and hands on instruction on how to conduct follow-up that includes re-engagement with treatment participants. This instruction is conducted weekly with the Drug and Alcohol Counselor. The Deputy Vice President of Human Services will monitor progress in this area. |