INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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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
The facility failed to conduct an unannounced fire drill for the months of October 2018 through January 2019, April 2019, June 2019 and July 2019.Additionally, the facility failed to identify, on their fire drill log, the amount of time it took for the evacuation, which exit route was used, and the number of persons in the facility at the time of the drill for every fire drill conducted from February 2019 to August 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Log was updated on 9/12/19 to include the amount of time it takes for evacuation, the exit route used and the number of persons in the facility at the time of the drill.
The new log will be fully implemented by 10/30/19.
The IS3 facility director is responsible for completing the log and the NPHS safety office is responsible for reviewing on a monthly basis.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to develop, and make available to the public, their 2018 annual report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No annual report for FY 2018 was completed because of the prior bankruptcy status of the institution.
The Sr. Vice President will complete and annual report for fiscal year ending June 30, 2019 by November 30, 2019.
Annual Report will be posted on the website by December 15, 2019
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No audit was completed for FY2018 because of the prior bankruptcy status of the organization.
The CFO is responsible for obtaining an audit for FY2019 and has engage a company to complete the audit.
Anticipated date of audit completion: December 30, 2019
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of eight client records reviewed.
Client # 1 was admitted on July 26, 2019 and was active at the time of the inspection. There was documentation of a letter to an attorney, that identified the client as a member of the drug and alcohol facility, dated August 7, 2019; however, there was no consent to release information form to the attorney on file prior to the disclosure.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of eight client records. Additionally, the facility failed to include the specific information that was to be disclosed on a consent to release information form in two of eight client records.
Client # 5 was admitted on March 11, 2019 and was active at the time of the inspection. The record contained a consent to release information form to a parole officer signed and dated by the client on June 5, 2019, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of history and physical exam, lab test results, UDS, information regarding care provided and ongoing care needs, and psychiatric evaluations. Additionally, there was documentation of a facsimile sent to a government agency that disclosed the urinalysis lab results.
Client # 7 was admitted on January 2, 2019 and was discharged on April 11, 2019. There was a consent to release information form to a government agency signed and dated by the client on January 8, 2019; however, the consent form did not include the specific information to be disclosed.
Client # 8 was admitted on April 1, 2019 and was discharged on June 17, 2019. There was a consent to release information form to the funding source signed and dated by the client on April 1, 2019; however, the consent form did not include the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms Including emphasis of the restrictions imposed by PA 255.5 with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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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
The facility failed to document the purpose of disclosure on the consent form in two of eight client records.
Client # 3 was admitted on October 23, 2018 and was discharged on February 4, 2019. There was a consent to release information form to a government agency signed and dated by the client on October 23, 2018; however, the consent form did not include the purpose for disclosure.
Client # 7 was admitted on January 2, 2019 and was discharged on April 11, 2019. There was a consent to release information form to a government agency signed and dated by the client on January 2, 2019; however, the consent form did not include the purpose for the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated signature of a witness on a consent to release information form in one of eight records.
Client # 8 was admitted on April 1, 2019 and was discharged on June 17, 2019. There was a consent to release information form to the funding source signed and dated by the client on April 1, 2019; however, the consent form did not include the dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to document that the client was offered a copy of the consent to release information form in three of eight client records.
Client # 5 was admitted to the on May 30, 2019 and was active at the time of the inspection. There was a consent to release information form to a parole officer signed and dated by the client on June 5, 2019; however, the consent form did not indicate whether the client was offered a copy.
Client # 6 was admitted to the on July 1, 2019 and was active at the time of the inspection. There was a consent to release information form to a government agency signed and dated by the client on July 1, 2019; however, the consent form did not indicate whether the client was offered a copy.
Client # 7 was admitted to the on January 2, 2019 and was discharged on April 11, 2019. There was a consent to release information form to a government agency signed and dated by the client
on January 2, 2019; however, the consent form did not indicate whether the client was offered a copy.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide documentation verifying that every client record reviewed was given written acknowledgement that they were informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record as part of their client rights.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation that the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental if presented to the client.
All active Participants will be provided the new form to sign-copies will be placed in their records and they will be offered a copy of the form.
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
The clinical Supervisors of the program will be responsible for insuring that all currently active participants are provided with and sign the updated form.
Completion will be by 10/30/19
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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
The facility failed to notify the Department within 3 days following an unusual incident, which involved a physical assault by a client to staff member occurring on February 18, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the policy regarding the reporting of Unusual Incidents to DDAP with the staff by November 1, 2019.
Copies of the Unusual Incident report form will be placed on the desk top of all clinicians and nursing stations for provide for easy access to the form.
The Clinical supervisor will perform a focus review for 60 days to be completed by December 31, 2019. Random ongoing review/monitoring will continue indefinitely thereafter.
Completion December 31, 2019 |
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
The facility failed to notify the Department within 3 days following an unusual incident, which required the presence of ambulance personnel on February 18, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the policy regarding the reporting of Unusual Incidents to DDAP with the staff by November 1, 2019.
Copies of the Unusual Incident report form will be placed on the desk top of all clinicians and nursing stations for provide for easy access to the form.
The Clinical supervisor will perform a focus review for 60 days to be completed by December 31, 2019. Random ongoing review/monitoring will continue indefinitely thereafter.
Completion December 31, 2019 |