INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 18, 2011 through January 19, 2011 licensure renewal inspection. The follow-up inspection was conducted on June 22, 2011 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:
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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.
This was still out of compliance at the time of the follow-up conducted on June 22, 2011.
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Plan of Correction
The Human Resources Director and the Facility Director reviewed personnel file #1. This staff person is on vacation and will retrun on August 15, 2011. Upon return of this staff person the assessment of staff training needs form will be completed for fiscal year ending June 30, 2010, signed by the appropriate parties and filed in the personnel file. A system of accountability establised on August 2, 2011 consists of quarterly audits of personnel files for compliance with policy and procedures. The quarterly audits will be conducted by the two Directors. |
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.
This was still out of compliance at the time of the follow-up conducted on June 22, 2011.
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Plan of Correction
As of August 2, 2011 the Facility Director has met with the Human Resources Director to review the personnel #1 file. This staff person is on vacation. Upon return on August 15, 2011 all training feeback forms will be completed and filed in the the personnel file. An accountability system has been designed. All staff trainings will be noted on the Human Resources and Facility Director's calenders. Upon completion of any outside trainings the trainee is responsible to submit the training certificate to the Human Resources Director at which time a feedback form will be given for completion in the presence of the Human Resources Director and filed in the personnel file immediately. When the trainings are facilitated in-house, feedback forms will be provided during the trainings and turned in along with the training certificate to the Facility Director or Human Resources Director at the conclusion of each training. This process will be continuously monitored by the Facility Director with the support of the Human Resources 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.
This was still out of compliance at the time of the follow-up conducted on June 22, 2011.
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Plan of Correction
As of August 2, 2011 the Facility Director and Human Resources Director have assessed personnel file #1. This individual is on vacation. Upon return on August 15, 2011 the individual training plan for fiscal year ending June 30, 2010 will be completed and signed by all interested parties and filed in the personnel file for this staff person. The system of accountability consisting of continous monitoring compliance with this policy procedure will be coducted by both the Facility Director and the Human Resources Director. This system of accountability was implemented on August 2, 2011 and consists of quarterly personnel file reviews conducted by the two Directors. |
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.
This was still out of compliance at the time of the follow-up conducted on June 22, 2011.
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Plan of Correction
This personnel file has been reviewed by the Human Resources Director and the Deputy Vice President of Human Services. The personnel file for personnel #1 has been updated to include the accurate number of training hours. As of August 2, 2011 all appropriate documentation regarding observation #0075 has been corrected. Effective August 2, 2011, the Deputy Vice President of Human Services will facilitate quarterly reviews of personnel files and address any deficiencies identified. |
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
Based on a review of fire drill records and an interview with the director, the facility failed to conduct fire drills monthly.
The findings include:
The fire drill records were reviewed on June 22, 2011. Fire drills were not conducted for the months of March 2011, April 2011 and May 2011. The last fire drill was conducted on February 2011. An interview with the director confirmed that there had been no fire drills since February 2011.
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Plan of Correction
The Facility Director has met with the staff in the clinical building to secure review the collaboration conducting fire drills. Due to critical staff turnover some processes were not translated comprehensively. This communication and the understanding that fire drills are required monthly has been re-establised as of August 2, 2011.Fire drills will be conducted monthly, at varying times of the operating schedule using various exits. There are 5 managers who work out of this facility. A schedule will be developed for the 12 month calender year that identifies who will be responsible for the fire drill and for which month. This will ensure better accountability for monthly fire drills in a multi-service setting and promote collaboratin amoung staff in the fire drill process. The scheduled will be developed by placing the 12 months in a bowl had allowing each manager to draw from the bowl. The Facility Director has agree to take on the excess months. Because we have some key staff on vacation, the schedule will be developed by August 15, 2011 |
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 records 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 June 22, 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 8:00 PM and Saturday 9:00 AM to 3:00 PM. Fire drills were not conducted for the months of March 2011, April 2011 and May 2011 on any shifts. The latest a fire drill was conducted was in February 2011 at 12:31 PM. An interview with the directors confirmed that there had been no fire drills since February 2011.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the January 18, 2011 through January 19, 2011 licensing inspection. The facility's plan of correction submitted on February 28, 2011 and approved on February 28, 2011 stated the following:
"Proyecto Nueva Vida has worked with the maintenance staff and the Mental Health Clinic, that operates in the same building, to schedule combined fire drills during the hours between 5 pm and 8 pm. 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."
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Plan of Correction
The Facility Director has met with the staff in the clinical building to secure review the collaboration conducting fire drills. Due to critical staff turnover some processes were not translated comprehensively. This communication and the understanding that fire drills are required monthly has been re-establised as of August 2, 2011.Fire drills will be conducted monthly as a regular part of Proyecto Nueva Vida operations. These monthly fire drills will be conducted between the hours of 8:30am - 8:00pm, Monday through Friday and 9:00am - 3:00pm on Saturdays. These fire drills will make use of the various building exits and be overseen by the Facility Director. Fire drills be be conducted beginning August 2011. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility's policy and procedure manual and an interview with the counselor the facility failed to document the client's medical history in accordance with facility policy in three of five client records reviewed.
The findings include:
Per the facility's policy and procedure manual that client histories will be completed within 30 days of the client's admission date.
On June 22, 2011 five client records requiring documentation of medical histories were reviewed. The facility failed to document medical histories in three of five records reviewed, specifically, records #2, 4 and 5.
Client #2 was admitted on March 8, 2011 and their medical history should have been completed by April 8, 2011. There was no documented medical history in the client record at the time of this inspection.
Client #4 was admitted on March 16, 2011 and their medical history should have been completed by May 16, 2011. There was no documented medical history in the client record at the time of this inspection.
Client #5 was admitted on May 9, 2011 and their medical history should have been completed by June 9, 2011. There was no documented medical history in the client record at the time of this inspection.
An interview with the counselor on June 22, 2011 confirmed the findings.
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Plan of Correction
The Facility Director will conduct an audit all clinical records on August 5, 2011 and provide training to counselors on areas of deficiency. The Faility Director will conduct weekly supervision with clinical staff to monitor progress in this area. Weekly monitoring in this area will be facilitated by the Facility Director. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility's policy and procedure manual and an interview with the counselor the facility failed to document the client's drug and alcohol history in accordance with facility policy in three of five client records reviewed.
The findings include:
Per the facility's policy and procedure manual, client histories will be completed within 30 days of the client's admission date.
On June 22, 2011 five client records requiring documentation of drug and alcohol histories were reviewed. The facility failed to document drug and alcohol histories in three of five records reviewed, specifically, records #2, 4 and 5.
Client #2 was admitted on March 8, 2011 and their drug and alcohol history should have been completed by April 8, 2011. There was no documented drug and alcohol history in the client record at the time of this inspection.
Client #4 was admitted on March 16, 2011 and their drug and alcohol history should have been completed by May 16, 2011. There was no documented drug and alcohol history in the client record at the time of this inspection
Client #5 was admitted on May 9, 2011 and their drug and alcohol history should have been completed by June 9, 2011. There was no documented drug and alcohol history in the client record at the time of this inspection
An interview with the counselor on June 22, 2011 confirmed the findings.
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Plan of Correction
The Facility Director will conduct an audit all clinical records on August 5, 2011 and provide training to counselors on areas of deficiency. The Facility Director will conduct weekly supervision with clinical staff to monitor progress in this area. The Facility Director with also provide inservice instruction in this area as needed. |
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.
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Observations
Based on the review of client records, the facility's policy and procedure manual and an interview with the counselor the facility failed to document the client's personal history in accordance with facility policy in three of five client records reviewed.
The findings include:
Per the facility's policy and procedure manual, client's histories will be completed within 30 days of the client's admission date.
On June 22, 2011 five client records requiring documentation of personal histories were reviewed. The facility failed to document personal histories in three of five records reviewed, specifically, records #2, 4 and 5.
Client #2 was admitted on March 8, 2011 and their personal history should have been completed by April 8, 2011. There was no documented personal history in the client record at the time of this inspection.
Client #4 was admitted on March 16, 2011 and their personal history should have been completed by May 16, 2011. There was no documented personal history in the client record at the time of this inspection.
Client #5 was admitted on May 9, 2011 and their personal history should have been completed by June 9, 2011. There was no documented personal history in the client record at the time of this inspection.
An interview with the counselor on June 22, 2011 confirmed the findings.
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Plan of Correction
The Facility Director will conduct an audit all clinical records on August 5, 2011 and provide training to counselors on areas of deficiency. The Facility Director will conduct weekly supervision with clinical staff to monitor progress in this area. The Facility Director with also provide inservice instruction in this area as needed. |
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 the review of client records, the facility's policy and procedure manual and an interview with the counselor, the facility failed to document a psychosocial evaluation that evaluated the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor ' s conclusion and impression in one of five client records reviewed. In addition, the facility failed to document a psychosocial evaluation in accordance with facility policy in four of five records reviewed.
The findings include:
Per the facility's policy and procedure manual, psychosocial evaluations will be completed within 30 days of the client's admission date.
On June 22, 2011 five client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation that evaluated the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor ' s conclusion and impression in one of five client records reviewed, and failed to document a psychosocial evaluation in four of five records reviewed.
The psychosocial evaluation in client record #1 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor ' s conclusion and impression of the client.
Client #2 was admitted on March 8, 2011 and their psychosocial evaluation was to be completed by April 8, 2011. There was no documented psychosocial evaluation in the client record at the time of this inspection.
Client #3 was admitted on April 8, 2011 and their psychosocial evaluation was to be completed by May 8, 2011. There was no documented psychosocial evaluation in the client record at the time of this inspection.
Client #4 was admitted on March 16, 2011 and their psychosocial evaluation was to be completed by April 16, 2011. There was no documented psychosocial evaluation in the client record at the time of this inspection.
Client #5 was admitted on May 9, 2011 and their psychosocial evaluation was to be completed by June 9, 2011. There was no documented psychosocial evaluation in the client record at the time of this inspection.
An interview was conducted with the counselor on June 22, 2011 and the counselor confirmed the findings.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the January 18, 2011 through January 19, 2011 licensing inspection. The facility's plan of correction submitted on February 28, 2011 and approved on February 28, 2011 stated the following:
"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 identify assets/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."
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Plan of Correction
The Facility Director will conduct an audit all clinical records on August 5, 2011 and provide training to counselors on areas of deficiency. The Facility Director will conduct weekly supervision with clinical staff to monitor progress in this area. The Facility Director with also provide inservice instruction in this area as needed. The instruction wil address best practices in identifying assests/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment. This instruction will ensure clinical accuaracy in the completion of biopsychosocial evaluations. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility's policy and procedure manual and an interview with the counselor, the facility failed to document an individualized comprehensive treatment plan in four of five records reviewed.
The findings include:
Per the facility's policy and procedure manual the client's comprehensive treatment plan will be completed within 30 days of the client's admission date.
On June 22, 2011 five client records requiring documentation of an individualized comprehensive treatment plan were reviewed. The facility failed to document an individualized comprehensive treatment plan in four of five records reviewed.
Client #2 was admitted on March 8, 2011 and their comprehensive treatment plan should have been completed by April 8, 2011. There was no individualized comprehensive treatment plan in the client record at the time of this inspection.
Client #4 was admitted on March 16, 2011 and their comprehensive treatment plan should have been completed by May 16, 2011. There was no individualized comprehensive treatment plan in the client record at the time of this inspection.
Client records #3 and 5 had treatment plans that were documented before the completion of the client's medical, personal and drug and alcohol histories, and psychosocial evaluations.
Client #3 was admitted on April 8, 2011 and their comprehensive treatment plan was documented on April 28, 2011. The client's medical, personal and drug and alcohol histories, and psychosocial evaluations were not documented in the client's record at the time of this inspection.
Client #5 was admitted on May 9, 2011 and their comprehensive treatment plan was documented on May 9, 2011. The client's medical, personal and drug and alcohol histories, and psychosocial evaluations were not documented in the client's record at the time of this inspection.
An interview with the counselor on June 22, 2011 confirmed the findings.
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Plan of Correction
The Facility Director will conduct an audit all clinical records on August 5, 2011 and provide training to counselors on areas of deficiency. The Facility Director will conduct weekly supervision with clinical staff to monitor progress in this area. The Facility Director with also provide inservice instruction in this area as needed. The instruction wil address best practices in the timely completion of comprehenvise treatment plans. This instruction will ensure clinical accuracy in the completion of comprehensive treatment plans. |
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 the review of client records, the facility's policy and procedure manual and an interview with the counselor, the facility failed to document case consultation notes in three of three client records reviewed.
The findings include:
Per the facility's policy and procedure manual case consultations were to be documented within 90 days of the client ' s admission date and 90 days thereafter.
On June 22, 2011 three client records requiring documentation of case consultations were reviewed. The facility failed to document case consultation notes in accordance with facility policy in client records, #1, 2 and 4.
Client #1 was admitted on January 31, 2011 and their case consultation was to be documented by May 1, 2011. There was no documentation of a case consultation in the client record at the time of this inspection.
Client #2 was admitted on March 8, 2011 and their case consultation was to be documented by June 6, 2011. There was no documentation of a case consultation in the client record at the time of this inspection.
Client #4 was admitted on March 16, 2011 and their case consultation was to be documented by June 14, 2011. There was no documentation of a case consultation in the client record at the time of this inspection.
An interview with the counselor on June 22, 2011 confirmed the findings.
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Plan of Correction
The Facility Director will conduct an audit all clinical records on August 5, 2011 and provide training to counselors on areas of deficiency. The Facility Director will conduct weekly supervision with clinical staff to monitor progress in this area. The Facility Director with also provide inservice instruction in this area as needed. The instruction will address best practices in the timely completion of case consultations . This instruction will ensure clinical accuracy in the completion of case consultations. |