INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6-9, 2018 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
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Plan of Correction
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual report. The 2016 annual report was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence for Bankruptcy NPHS will complete an annual report- the first report will cover FY 7-1-2017 thru 6-30-2018. The Sr. Vice President and CEO will ensure that annual reports are completed on or before September 30th of each year.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual audit. The 2016 annual audit was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence from Bankruptcy NPHS will complete its annual audit and file a copy with DDAP. The CEO/Sr. Vice President will ensure that the audit is done on an annual basis. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on the review of seven client records on February 8-9, 2018, the facility failed to obtain valid consent to release forms in client records, #1 and 4.
Client #1- A consent to release to the clients funding source failed to have the date the client signed.
Client #4 - The facility failed to document on a consent to release, for an agency, what specific information was going to be release. Additionally, there were several consent to release forms of another client, in client #4's record.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The training coordinator will provide two trainings focusing on the appropriate way to complete a consent to release form. This training will also include identifying specific contacts that require a consent to release information, as well as what information that may be released to various agencies and individuals. |
709.51(a)(1) LICENSURE Criteria for Admission
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on a review of seven client records on February 8-9, 2018, the facility failed to provide physical examinations during intake in client records, #1, 4 and 7.
Client #1- was admitted on 10/31/17 and did not received their physical until 12/22/17.
Client #4- was admitted on 11/20/17 and did not received their physical until 11/28/17.
Client #7- was admitted on 7/12/17 and did not received their physical until 9/11/17.
These findings were discussed with the facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor and the unit assigned nurse will assure that all clients are scheduled to have a physical examination within 7 days of their admission. The nurse will document all scheduled history and physical appointment on a monthly calendar that will be reviewed by the clinical supervisor daily. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of seven client records on February 8-9, 2018, the facility failed to provide evaluative evaluations for clients, #1, 4, 5, 6 and 7. The facilty only documented what the clients stated.
These findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will conduct an assessment and identify all clinicians who struggle with writing an evaluative evaluation. Once these individuals are identified they will attend assessment and clinical formulation training provided by CBH network development department. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 review of three discharged records on February 8-9, 2018, the facility failed to provide documentation of a follow-up for all three clients reviewed.
Client #5 was admitted on 9/19/16 and discharged on 2/1/17.
Client #6 was admitted on 1/30/17 and discharged on 7/10/17.
Client # 7 was admitted on 7/12/17 and discharged on 1/10/18.
These findings were reviewed with the facility during the licensing inspection.
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Plan of Correction
The clinical supervisor will conduct a monthly audit of 25% of the clients who have been discharged to assure that the all follow procedures are completed |