INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2008 through August 15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health Systems 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 15, 2008.
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Plan of Correction
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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 fire drills records, the facility failed to document unannounced monthly fire drills at least once per month.
Findings:
The facility failed to document a fire drill for the month of July 2008.
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Plan of Correction
A mandatory in-service was held on Monday, August 25, 2008 at 10am. All managers from the Tower building were required to attend. The Fire Marshall presented the education. A review was completed regarding the process for completiing the fire drill documentation. A new process was put in place which requires all documentation from the unit to be submitted to the CEO's office within 24 hours of the fire drill. All documentation will be reviewed for content and completeness by the CEO. If the documentation is incomplete, the manager will be notified to correct the issue. This will begin immediately. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill records on August 11, 2008, the facility failed to document the exit route used during a fire drill.
Findings:
There was no documentation of the exit routes used during the fire drill in the fire drill log for nine of the last nine fire drills.
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Plan of Correction
Mandatory education was provided to all Tower managers by the Fire Marshall on 8/25/2008 at 10am. One agenda item of this education was the use of the alternate fire tower exit in the Tower building. The Fire Marshall will review the process of using this exit with each manager. The Fire Marshall will go down the fire exit with each manager to make sure they are familiar with the route. By December 1, 2008, all managers will be educated and a fire drill will be conducted utilizing this alternate route. Appropriate documentation of this drill utilizing the alternate route will be submitted to the CEO for review and then placed in the Fire Drill Documentation Binder. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of four client records on August 12 and 13, 2008, the facility failed to provide for informed consent on the consent to release information forms and the client orientation forms and failed to properly inform the client of releases without written consent and the need for a court order in four of four client records reviewed.
Findings:
The facility did not provide documentation to demonstrate that the clients represented by client records # 1, 2, 3 and 4 were informed of the right to revoke consents to release information verbally. The 'Confidential Information' section of the 'Consent to Treatment' form failed to advise the client that a court order would be required in order for the facility to release information regarding suicidal or homicidal intent without the client's written consent.
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Plan of Correction
The Confidential information of the consent to treatment form will be revised. These items will be added.
1. you have the right to verbally revoke consent to release information.
2. a court order is needed to divulge information without consent for clients expressing suicidal or homicidal ideation and/or intent.
This change was completed by the Director of Residential Services, the VP of Behavioral Medicine and the Director of Patient/Client Access. This will be completed by 9/30/2008. |