INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 2015 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:
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Plan of Correction
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711.51(b)(7) LICENSURE Preliminary Tx Plan
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in two of eight client records.
The findings include:
Eight client records were reviewed on August 12, 2015. All were reviewed for preliminary treatment and rehabilitation plans. The facility failed to document a preliminary treatment plan during the intake process in client records, #1 and 2.
Client #1 was admitted on July 24, 2015 and is still an active client. The facility failed to document a preliminary treatment and rehabilitation plan as of the date of the licensing inspection.
Client #2 was admitted on June 17, 2015 and is still an active client. The facility failed to document a preliminary treatment and rehabilitation plan as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will monitor all admissions for the next 90 days to ensure that preliminary treatment plans are completed on all new admissions.
The Program Director will release a memo regarding preliminary treatment plans/updated treatment plans on participants who are readmitted following hospitalizations by September 20, 2015.
The Director will monitor all readmissions for compliance for the next 90 days. |
711.56(a) LICENSURE Written Termination Notice
711.56. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one client records.
The findings include:
Eight client records were reviewed on August 12, 2015. One client record was reviewed for a notice of termination. The facility failed to document a notice of termination in client record, #8.
Client #8 was admitted on October 27, 2014 and involuntarily terminated on January 21, 2015. There was no documentation of a written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct an inservice with the Behavioral Specialist regarding notification of intent to discharge on or before September 30, 2015 to review policy and procedure.
All administrative discharges will require Directors approval and signature in order to ensure that they are given to participants.
The Director conduct a focused monitor of administrative discharges for the next 90 days to insure that any and all involuntary terminations recieve notification. |