INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23 through October 26, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System, 11th Floor Tower, 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 November 26, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records on 10/23/07, the facility failed to document feedback on completed training in four of four records reviewed, #1, 2, 3 and 4.
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Plan of Correction
Training feedback forms were initiated in January 2007 and will be avilable for all training session during training year January-December 2007 and beyond. The Program Director and or his disegnee will monitor for compliance. |
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 training records on 10/23/07, the facility failed to document HIV/AIDS training for one of four employee records reviewed, #4.
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Plan of Correction
HIV training is scheduled for November 30, 2007 all staff members who have not had training will be scheduled. HIV training is provided quarterly on site. The Program Director will monitor the training records on a quarterly basis to ensure compliance with training regulations. |
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 administrative records on 10/26/07, the facility failed to document that alternate exit routes were used during fire drills for nine of nine fire drills reviewed.
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Plan of Correction
In service training on the accurate completion of fire drill logs will be provided by the saftey office to all staff on or before December 31, 2007. These logs include the disignation of the exit route used during the drill and will document alternate routes. The Program Director will monitor on a montly basis the accurate completion of the form. |
711.52(c)(1) LICENSURE Treatment goals
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records on 10/24/07, the facility failed to document goals stated in terms of measurable criteria in four of four client records reviewed, #1, 2, 4 and 5.
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Plan of Correction
Inservice training regarding treatment planning will be provided by the education department on or before January 15, 2008.
Effective immediately increased clinincal supervision will be provided by the Program Director who will monitor the documentaion of measurable goals and objectives and provide one on one instruction. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records on 10/24/07, the facility failed to document an assessment of progress in relationship to the stated goals of the prior treatment plans in three of four client records reviewed, #1, 2 and 5.
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Plan of Correction
Effective September 2007 a new treatment plan format was iniated in all Residential programs. The new format requires the assessment of progress on the prior goals and objectives. The Program Director will monitor the accurate completion of the treatmnt plan in monthly clinical supervision. |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records on 10/24/07, the facility failed to document an informed and voluntary consent in four of four records reviewed. The specific information to be disclosed to SSI exceeded that allowed by 4 Pa. Code 255.5 in three of four records reviewed, #2, 4 and 5. Additionally, the specific information to be disclosed was left blank in one of four records reviewed, #1.
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Plan of Correction
The Program Director will provide inservice training on the completion of release of information forms on or before December 15, 2007. The Program Director will monitor the accurate completion of forms on a monthly basis. |