INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 6, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client # 1 was admitted on February 17, 2021 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted on January 19, 2021 and was discharged on April 23, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
*Clinical supervisor will review Client#1 and Client#2 with assigned counselor(s)to discuss importance of obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record by June 18 , 2021
#Assigned counselor(s) will complete a new ROI active client(s) by June 18, 2021.
*Clinical Supervisor will provide a in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents by June 18, 2021
*Clinical Supervisor will conduct random audits of three(3)charts per clinician each month to validate that staff by members are correctly completing consent forms by June 18, 2021 and ongoing review of charts.
*Clinical Supervisor will document outcome of consent chart audit in Performance Improvement report quarterly by June 18, 2021.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in six of seven client records reviewed.
Client # 1 was admitted on February 17, 2021 and was still active at the time of the inspection. The release of information form to a government agency was signed and dated by the client on February 17, 2021, but the form did not document the purpose of the disclosure.
Client # 2 was admitted on February 10, 2021 and was still active at the time of the inspection. The release of information form to a government agency was signed and dated by the client on February 10, 2021, but the form did not document the purpose of the disclosure.
Client # 3 was admitted on February 18, 2021 and was still active at the time of the inspection. The release of information form to a government agency was signed and dated by the client on February 18, 2021, but the form did not document the purpose of the disclosure.
Client # 4 was admitted on March 16, 2020 and was discharged on August 20, 2020. The release of information form to a government agency was signed and dated by the client on March 16, 2020, but the form did not document the purpose of the disclosure.
Client # 5 was admitted on January 19, 2021 and was discharged on April 23, 2021. The release of information form to a government agency was signed and dated by the client on January 19, 2021, but the form did not document the purpose of the disclosure.
Client # 6 was admitted on November 6, 2020 and was discharged on March 8, 2021. The release of information form to a government agency was signed and dated by the client on November 6, 2020, but the form did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
*Clinical supervisor will review Client#1,Client#2,Client#3,Client#4,Client#5 and Client#6 with assigned counselor(s)to discuss importance of documenting the purpose of the of disclosure on consents forms. If , clients are active on units , new ROI 's will be signed by June 14 ,2021
*Clinical Supervisor will provide an in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents and purpose of the disclosure by June 18, 2021
*Clinical Supervisor will conduct random audits of three (3)charts per clinician each month to validate that staff members are correctly completing consent forms by June 18, 2021 and ongoing review of charts.
*Clinical Supervisor will document outcome of consent chart audit in Performance Improvement report quarterly by July 9 ,2021.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's October 2019 through April 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following incidents at the facility of physical assaults involving clients on May 9, 2020, September 11, 2020, December 30, 2020, and January 31, 2021
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Incident reports will be submitted for all incidents noted in the citation by the administrative assistant of the Program by June 4, 2021.
Responsible party-Administrative Assistant
Date of compliance 6-4-2021
Beginning June 1, 2021 Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning June 1, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: June 4, 2021
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's October 2019 through April 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident that required the presence of police and/or ambulance personnel at the facility on February 10, 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Incident reports will be submitted for all incidents noted in the citation by the administrative assistant of the Program by June 4, 2021.
Responsible party-Administrative Assistant
Date of compliance 6-4-2021
Beginning June 1, 2021 Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning June 1, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: June 4, 2021
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