INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2010 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 and a plan of correction is due on September 24, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Six personnel records were reviewed on August 11, 2010 through August 16, 2010 and the staffing requirements facility summary report was reviewed on August 11, 2010 through August 12, 2010. There was no documentation of HIV/AIDS or TB/STD training in three employee records. All three were required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #6 was hired August 8, 2005 and was required to have HIV/AIDS & TB/STD training by August 8, 2007. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of August 16, 2010.
Employee #7 was hired February 2007 and was required to have HIV/AIDS & TB/STD training by February 2009. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #8 was hired October 2007 and was required to have HIV/AIDS & TB/STD training by October 2009. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
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Plan of Correction
The New Employee orientation will be modified to include HIV/AIDS and First Aid training along with the TB/STD and CPR training in order to insure that all new hires obtain the DOH mandatory training requirements. The infection disease department will be responsible for providing HIV/AIDS and the education department will be responsible for providing First Aid. The modification will take place by November 2010.
By December 31, 2010 all current staff who is not compliant for training will receive the DOH mandatory training.
The Program Directors and the AVP or nursing will be responsible for ensuring that all staff has obtained required training.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a tour of the facility ' s physical plant and an interview with the facility director, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The facility was required to ventilate all toilets and wash rooms by exhaust fan or window. The facility did not ventilate the wash rooms in client bedroom # 1102 and 1107.
The facility director confirmed that ventilation was not provided in the identified wash rooms.
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Plan of Correction
All the vent motors were replaced during the survey. The Director of Plant Facilities will place the monitoring of vent motors as a part of the monthly preventative maintenance rounds. Fully compliance August 26, 2010.
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705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a tour of the facility ' s physical plant and an interview with the facility director, the facility failed to ensure that storage areas for food are free of food particles, dust and dirt.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The facility was required to ensure that storage areas for food are free of food particles, dust and dirt.
The cabinets in the kitchen on the 11th floor were not free of food particles, dust and dirt.
The facility director confirmed that the cabinets in the kitchen were not free of food particles, dust and dirt.
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Plan of Correction
The environmental rounds board will be modified to include inspection of the pots and pans area for food particles by September 17, 2010. The reports will be monitor by the Program Director. The program will be in compliance immediately. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
The facility fire drill record did not include any record of a fire drill for June 2010.
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The staff person questioned confirmed that there was no documentation of a June 2010 Fire drills, nor were there any observation sheets completed for December 31, 2009.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The fire drill conducted on November 27, 2009 failed to document the exit route used.
The fire drill conducted on January 18, 2010 did not identify the exit route.
The fire drill record of February 25, 2010 only contained documentation for the ninth floor of the Tower building.
The fire drill conducted on April 6, 2010 did not include the number of participants.
The fire drill conducted on May 26, 2010 had a note that the indicated no evacuation due to early morning.
The staff person questioned confirmed the findings.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation to include the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions in four of six client records reviewed.
The finding includes:
Six records were reviewed on August 19, 2010. Psychosocial evaluations were required in Six records reviewed.
Client records #1 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and client attitude toward treatment.
Client records #2 failed to document the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client record #3 and 4 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions.
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Plan of Correction
The Director of Outpatient Psychiatry will develop a three hour training sessions on completing psychosocial evaluations and will provide the training to all clinical staff by November 30, 2010.
A psychologist from the Outpatient Department will conduct random reviews of evaluations and meet with clinical staff to review case formulations/evaluations for the next 90 days.
The clinical supervisors will review three cases per month of each clinician for the next 90 days, focusing on psychosocial evaluations.
Ongoing monitoring will be conducted by the clinical supervisors and full compliance will occur by December 31, 2010.
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