INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14-15, 2009 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 October 24, 2009.
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Plan of Correction
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705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a tour of the facility's physical plant, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
The findings include:
A tour of the facility ' s physical plant was conducted on September 23, 2009 at approximately 9:30 AM. The facility was required to have at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen. The facility did not have a fire extinguisher in the kitchen located on the 11th floor.
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Plan of Correction
The maintenace department will hang a ABC fire extingisher with the kitchen area by October 31, 2009. The safety department will monitor the extingisher on a monthly basis. Full compliance will be obtained by October 31, 2009 |
711.52(e) ELEMENT Provision of services
711.52. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records the facility failed to assure that counseling services were provided according to the client's individual treatment plan in three of five client records.
The findings include:
Five client records were reviewed on September 14-15, 2009. All five records were reviewed for the provision of counseling services in accordance with the client's treatment plan. The facility did not document missed group counseling sessions in a progress note or in the record of service in client record # 1, 2 and 3.
Client record #1 treatment plan dated 7/15/09 and all subsequent treatment plan updates stated group counseling sessions were to be conducted two times monthly, but group session progress notes were only documented on 8/27/09.
Client record #2 treatment plan dated 7/3/09 and all subsequent treatment plan updates stated group counseling sessions were to be conducted two times monthly, but group session progress notes were only documented on 7/29/09, 8/6/09 and 8/27/09.
Client record #3 treatment plan dated 6/22/09 and all subsequent treatment plan updates stated group counseling sessions were to be conducted two times weekly, but group session progress notes were only documented on 8/6/09 and 8/27/09.
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Plan of Correction
The Program Director/Clinical supervisor will provide an inservice training on or before 10/31/09 regarding the accurate completion of plans and charting attendance and lack of attendance in scheduled sessions. Attendance or lack of attendance will be charted in the progress notes.
The clinical supervisor will monitor on a monthly basis, compliance with these regulations during clinical supervision sessions. Full compliance will be achieved by November 30, 2009. |