INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 23, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of employee records, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum, within the required time frame.
The Findings include:
Two personnel records requiring documentation of HIV/AIDS training were reviewed during an Administrative Review conducted from August 6 - 8, 2012. One of two records, specifically # 6, contained documentation of HIV/AIDS training that was obtained after the required time frame.
Employee # 6, a Mental Health Worker, was hired by the facility in February 2007 and was required to obtain a minimum of 6 hours of HIV/AIDS training by February 2009. The record contained documentation of 6 hours of HIV/AIDS training that was obtained on July 16, 2012.
The findings were confirmed by the Vice President of Behavioral Health Services.
This is a repeat citation. The program was cited for noncompliance with this standard during the August 11, 2011 inspection.
|
Plan of Correction
HIV training has been added to the new employee orientation in order to insure compliance. Prior records of completion were maintained in a central office. Effective September 30, 2012 clinical supervisors will be responsible to maintain and monitor on a monthly basis personnel compliance with training regulations to avoid non compliance. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based upon the physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
The rear visitor's parking lot is shared between several programs contained within the project. A physical plant inspection was conducted on August 9, 2012 following the Administrative Site Visit , from approximately 12:00 PM to 12:30 PM and again upon arriving at the facility on August 23, 2012. The parking lot contained several potholes and loose macadam / stones from the potholes, which presented a hazard to residents, employees, and / or visitors.
The findings were confirmed by the program's Fire and Safety Supervisor.
This is a repeat citation. The program was cited for noncompliance with this standard during the August 11, 2011 inspection.
|
Plan of Correction
The visitor's parking lot will be resurfaced on or before October 31, 2012. The Facilities director will be responsible for insuring that the lot is inspected on a regular basis and that new potholes are repaired as they occur.
|
711.53(a)(8) LICENSURE Work as Therapy
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(8) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
|
Observations
Based upon a review of the facility's Policy & Procedures (P&P) Manual and client records, the facility failed to verify that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
The facility's P&P Manual was reviewed as part of an Administrative Review conducted from August 6 - 8, 2012. As per the P&P Manual, clients engage in the clean up and maintenance of their personal surroundings as well as common group areas.
Five client records requiring verification that work done by the client is an integral part of their treatment plan were reviewed from August 23, 2012. Five of five records, specifically #'s 1, 2, 3, 4, and 5 did not contain documentation that verified that work completed by the clients was an integral part of their treatment plan.
Client # 1 was admitted on July 13, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 2 was admitted on July 10, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 3 was admitted on July 16, 2012, and was discharged on August 20, 2012. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 4 was admitted on July 30, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 5 was admitted on July 3, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
The findings were confirmed by the Clinical Director during the exit interview.
|
Plan of Correction
The clinical supervisor will review the policy regarding work therapy and its documentation with the clinical staff by September 30, 2012. The clinical supervisor will monitor all treatment plans during the month of October to ensure that documentation is complete. The unit will be in full compliance bey October 31, 2012. The clinical supervisor will conduct random monitoring of Treatment plans to ensure ongoing compliance. |