INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2016 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:
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Plan of Correction
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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.
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Observations
A physical plant inspection was conducted on August 17, 2016.
Room 1005 had a cover missing on a vent and a crack in the wall.
Room 1003 had a hole in the wall behind the door.
Room 1002 had chipped paint on the wall and a light fixture had rust around it. Additionally, there was a crack in the wall in the hallway that connects this room to the bathroom.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016. |
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
The physical plant inspection was conducted on August 16, 2016 and August 17, 2016. The facility's trash compactor outside of the kitchen was filled to the point that it was unable to to be closed, thus unable to to prevent the penetration of insects and rodents.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Housekeeping is responsible for insuring that the trash compacted is empty of a timely basis, in order to prevent access by pest and rodents. The trash compacted is scheduled to be emptied on a daily basis, she will monitor the removal of trash and insure that the compactor can be closed beginning immediately. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Five personnel records were reviewed on August 16, 2016.
Employees #2 and #4 did not have documentation of an annual written individual staff performance evaluation from the previous reviewing year
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Plan of Correction
The Vice President of Residential Services will review and complete all overdue performance evaluation by 10/30/2016. The supervisor will develop a tickler file regarding annual evaluation dates and monitor and complete evaluations on a monthly basis as indicated. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Seven client records were reviewed on August 17, 2016 for informed voluntary consents to release information in accordance with 42CFR and 4 Pa. Code The facility failed to obtain informed and voluntary consents in seven of seven records reviewed.
42CFR Part 2 Subpart C States:
(a) Required elements. A written consent to a disclosure under these regulations must include:
(1) The specific name or general designation of the program or person permitted to make the disclosure.
(2) The name or title of the individual or the name of the organization to which disclosure is to be made.
(3) The name of the patient.
(4) The purpose of the disclosure.
(5) How much and what kind of information is to be disclosed.
(6) The signature of the patient.
(7) The date on which the consent is signed.
(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third party payer.
(9) The date, event, or condition upon which the consent will expire if not revoked before. This date, event, or condition must insure that the consent will last no longer than reasonably necessary to serve the purpose for which it is given.
4 Pa. Code States:
(b) Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Client #1- Consents to two government-related agencies allowed for the following information to be released, which exceeded 4 PA. Code psychiatric evaluation, psychosocial history, copies of progress notes, history and physical, and results of urine drug screen (UDS).
A consent to a doctor dated August 3, 2016, did not specify the purpose for the release.
Three consents for funding sources were not dated by the client.
The record contained two consent forms signed by the client with the following information missing: the releasing and receiving agency/individual, purpose of the disclosure, information being released, and whether or not the client received a copy. One of these consents was not dated by client.
At the time of the inspection, there was no purpose for release identified in the consent to the probation officer.
The unit releasing information in a consent to a family member was incorrectly entered.
Client #2- Consents to two funding sources were not dated by the client but dated by staff on July 28, 2016.
Another consent form failed to identify the purpose for disclosure, the date or condition the consent expires, and did not acknowledge whether or not the client received a copy.
Another consent form only specified the first name of the disclosure recipient, did not specify a purpose for disclosure, the information being released, whether the client accepted or declined a copy, and the date or condition of expiration.
Client #3- Consent form dated July 8, 2016 to a government agency did not specify if the client accepted or declined a copy of the consent.
Consent to a government-related agency allowed for the following information to be released, which exceeded 4 PA. Code psychiatric evaluation, psychosocial history, copies of progress notes, history and physical, and results of urine drug screen (UDS).
A referral to an outside agency was made on July 18, 2016, which included the release of the client's mental health and substance abuse related diagnoses. There was no consent in the record for this agency.
There were two consent forms that did not specify if the client accepted or declined a copy of the consent; one was to a another treatment facility
Client #4- Consents to two funding sources were not dated by the client but dated by staff on July 28, 2016.
A consent to release information to a doctor did not include whether the client accepted or declined a copy and the date or condition of expiration.
A consent to a government-related agency allowed for the following information to be released, which exceeded 4 PA. Code and did not identify a date or condition of expiration: psychiatric evaluation, psychosocial history, copies of progress notes, history and physical, and results of urine drug screen (UDS).
Another consent to a government-affiliated agency did not specify a date or condition of expiration or purpose of disclosure.
The consent for probation and parole did not specify the agency (locale or jurisdiction) or individual officer receiving information, the purpose for disclosure, or date or condition of expiration.
The record contained three consent forms signed and dated by the client with the following information missing: receiving agency/individual, purpose of the disclosure, and information being released.
A referral to a government-related agency was made on August 8, 2016, which included the release of the client's mental health and substance abuse related diagnoses. There was no consent in the record for this agency.
Client #5- In the consent to a doctor dated by staff on August 5, 2016, the purpose for disclosure was unclear, there was no acknowledgment if the client accepted or declined a copy, and it was not dated by the client.
A consent to a funding source dated by staff on June 21, 2016 was not dated by the client.
A consent form dated on July 14, 2016 did not specify if the client accepted or declined a copy.
A referral to an outside agency was made on July 20, 2016, which included the release of the client's mental health and substance abuse related diagnoses. There was no consent in the record for this agency.
Client #6- Consents to two funding sources dated by staff on November 2, 2015 were not dated by the client.
A consent to a doctor was signed with different dates by the staff member and client, November 28, 2015 versus December 28, 2015.
A consent form to a family member had the same expiration date as the date it was signed.
Progress notes indicated that contact was made with this family member after the consent expired.
The consent for probation and parole did not specify the agency (locale or jurisdiction) or individual officer receiving information and also expired the same date it was signed.
Consent to a government-related agency allowed for the following information to be released, which exceeded 4 PA. Code psychiatric evaluation, psychosocial history, history and physical, and results of urine drug screen (UDS).
Consent to an agency for continuity of care had no identified information to be released, but diagnoses were disclosed on December 3, 2015.
Client #7- Consents to two funding sources dated by staff on November 6, 2015 were not dated by the client.
The acronym of the agency entered on the consents to two family members was incorrectly entered on November 9, 2015.
Consents to two doctors were not dated by the client or the date or condition of expiration. One of the consents also did not specify a purpose for release.
A referral to a government-related agency was made on November 25, 2015, which included the release of the client's mental health and substance abuse related diagnoses. There was no consent in the record for this agency.
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Plan of Correction
All consent forms will be reviewed and updated by the Sr. Vice President of Behavioral Health Services to ensure conformance with DDAP regulations with specific attention to Client signature and date; in service training will be provided during unit staff meetings and new forms will be issued to all staff on or before September 30, 2016.
New and appropriately executed release forms will be completed on all active participants in the program by 10/31/16
Full compliance will be obtained by October 31, 2016. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Seven client records were reviewed on August 17, 2016 for documentation that the clients were informed of their rights. Seven out of seven records lacked documentation verifying written acknowledgement by clients that they had been notified of the client rights.
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Plan of Correction
The Sr. Vice President will review all Participant handbooks for content related to client rights. The Sr. Vice President will also review the client rights provided in the Behavioral Access Center to ensure that the forms contain appropriate Participant signatures. The clinical supervisor on the program and the BAC will monitor the process to ensure that Participants are signing that they have been notified of their rights. Full compliance will be achieved by October 15, 2016 |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Seven client records were reviewed on August 17, 2016 for preliminary treatment and rehabilitation plans. The facility failed to document preliminary treatment plans in three of seven records reviewed.
The facility failed to document preliminary treatment and rehabilitation plans in client records #2, 3, and 7 at the time of the inspection.
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Plan of Correction
The Director of Residential Services will review all new admissions to assure the initial intake process is completed, along with the preliminary treatment plan, during the morning treatment team meetings. This process is to assure that all preliminary treatment plans are implemented as required. The Plan of Correction will be reviewed and completed by 10/30/16 |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Seven client records were reviewed on August 17, 2016 for individual treatment plans. The facility failed to document the type and frequency of services in the individual treatment and rehabilitation plans in four of seven client records reviewed.
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Plan of Correction
By 10/31/16, The Clinical Supervisor of the IOP program will train all clinical staff on how to add a list of proposed support services when updating treatment plans.
By 10/31/16, The Clinical Supervisor of the IOP will train all of the clinical staff on how to include in the treatment plans, the frequency of treatment and rehabilitation services.
Beginning 11/1/16, the Clinical supervisor will inspect participants' electronic chart to ensure:
1. That treatment plans are completed on time and are located in the right electronic file.
2. that treatment plans include propose support services list
3. That treatment plans include frequency of treatment and rehabilitation services.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Three client records requiring documentation of treatment plan updates were reviewed on August 17, 2016. The facility failed to document a treatment plan update at least every 30 days in client record #6.
Client #6 was admitted on November 2, 2015. The individualized treatment and rehabilitation plan was completed on November 9, 2015. A review and update of the treatment and rehabilitation plan was due to be completed on December 9, 2015 but was not completed until December 21, 2015. An additional review and update of the treatment and rehabilitation plan was due to be completed on January 21, 2016 but was not completed until February 1, 2016.
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Plan of Correction
The Director of Residential Services will develop a list of records to be reviewed weekly. These records will be reviewed during the weekly treatment team meeting to assure that all required documentation and treatment plans are updated in-conjunction with the agency policy on treatment plan update by Oct. 30, 2016 |