INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2018 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 to be not 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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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
Administrative documents were reviewed on September 4, 2018 through September 5, 2018. The facility failed to present the financial audit for fiscal year 2017.
The facility director confirmed the finding.
This is a repeat citation
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Plan of Correction
The CEO will request an exception to 709.25 based on NPHS recent Bankruptcy. Compliance with the financial audit requirement cannot be met until December 2019
Responsible person: Gerri Walker
expected date of completion: 12/15/2018
If an exception is not grant the Project Director will submit a copy of the first financial audit which shall be available on or before June 2019. |
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
A review of seven client records revealed that the facility failed to obtain a valid consent for the disclosure of information from the client record.
Client #1's file contained a consent to an agency dated 06/19/18 that did not specify the purpose of the disclosure. A consent to a government agency dated 06/19/18 that indicated "other" was to be released but "other" was not specified and a consent to an agency dated 06/19/18 that did not indicate if a copy had been offered to the client.
Client #2's file contained a consent to a government agency dated 05/29/18 that indicated "other" was to be released but "other" was not specified.
Client #3's file contained a consent to a government agency dated 04/18/18 that did not specify the purpose of the disclosure. In addition "other" was checked as a purpose but no additional information was noted in this area. Additionally, two consents, one to an agency and one to family, dated 04/18/18 that did not specify what information was being released. Lastly, a consent to probation and parole dated 04/18/18 that did not indicate if a copy had been offered to the client.
Client #4's file contained three consents, one to an agency, one to a physician and one to a government agency, dated 03/05/18 that did not specify the purpose of the disclosure. Additionally, a consent to an agency dated 03/05/18 that did not specify what information was being released.
Client #5's file contained a consent to probation and parole dated 07/13/18 that did not specify the purpose of the disclosure. Additionally, a consent to family dated 09/10/18 that did not specify what information was being released.
Client #6's file contained four consents, two for agencies and two for government agencies, dated 06/27/18 that did not specify the purpose of the disclosure. Additionally, a consent to an agency dated 06/27/18 that did not specify what information was being released. Lastly, five consents, two for agencies, two for government agencies and one for a funder, dated 06/27/18 that did not indicate if a copy had been offered to the client.
Client #7's file contained a consent to a government agency dated 07/03/18 that did not specify the purpose of the disclosure. Additionally, a consent to a government agency dated 07/03/18 that did not indicate if a copy had been offered to the client.
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
The Clinical Supervisor will provide in-service training to all staff regarding the proper completion of consents, training will include all aspects of the consent .
Responsible Party: Clinical Supervisor Completion Date 1/15/19
Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that staff members are correctly completing all consents
Responsible Person- Clinical supervisor Completion Date 2/15/19
the clinical director will have corrected consent forms presented and explain to all active clients
responsible person- clinical director
completion date 11-16-18 |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
A review of seven client records revealed that the facility failed to document that clients had been informed of their rights.
Client #1 admitted 07/03/18 and discharged 08/01/18 did not have any documentation in his client record that he was informed of his rights.
Client #2 admitted 05/29/18 and discharged 08/22/18 did not have any documentation in his client record that he was informed of his rights.
Client #3 admitted 04/18/18 and discharged 06/18/18 did not have any documentation in her client record that she was informed of her rights.
Client #4 admitted 03/05/18 and discharged on 05/21/18 did not have any documentation in his client record that he was informed of his rights.
Client #5 admitted 07/13/18 did not have any documentation in her client record that she was informed of her rights.
Client #6 admitted 06/27/18 did not have any documentation in his client record that he was informed of his rights.
Clients #7 admitted 07/03/18 did not have any documentation in his client record that he was informed of his rights.
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
POC
The Clinical Supervisors will provide and in-service training to all staff on client rights and the responsibility to document that clients have been given and explained a copy of their rights.
Responsible Party: Clinical Supervisor Completion Date 1/15/19
Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that clients had been informed of their rights
Responsible Person- Clinical supervisor Completion Date 2/15/19
the clinical director will review the clients bill of rights to those active clients who where not informed of there rights review it with them, followed by having the client sign and date the bill of rights. a signed copy will be placed in the clients charts
responsible person- clinical director
completion date 11-16-18 |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to keep the grounds free from any danger to health and safety.
The ground exit from the east fire tower had cracks in the sidewalk and a fence that was damaged which allows access to a ledge leading to a subterranean 'pit'. Additionally, an exit door, located on the second floor had a window with a hole in the glass with jagged edges presenting a safety hazard.
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
The Landlord will completed repair of the exit, area and the broken window.
Responsible Party: IS3 Maintenance Department Date of Completion: 11-15-18
The Fire Marshal will monitor this area on a monthly basis, and report his findings to the VP of behavioral health
Responsible Party: Fire Marshal Completion Date: Beginning 10/20/18 & ongoing indefinitely
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709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
A review of seven client records revealed that the facility failed to document a plan in the client group notes.
Client #1's file contained group notes that did not have documentation of a plan on the following dates:
07/03/18
07/10/18
07/11/18
07/23/18
07/24/18
07/25/18
Client #2's file contained group notes that did not have documentation of a plan on the following dates:
05/30/18
06/13/18
07/03/18
07/09/18
07/10/18
07/11/18
07/16/18
07/23/18
07/24/18
07/25/18
08/06/18
08/14/18
08/21/18
Client #3's file contained group notes that did not have documentation of a plan on the following dates:
04/30/18
05/07/18
05/16/18
05/22/18
05/29/18
05/30/18
06/12/18
06/13/18
Client #4's file contained group notes that did not have documentation of a plan on the following dates:
03/06/18
03/13/18
03/29/18
04/11/18
04/17/18
05/16/18
Client #5's file contained group notes that did not have documentation of a plan on the following dates:
07/24/18
07/23/18
07/25/18
07/30/18
07/31/18
08/06/18
08/14/18
08/21/18
08/27/18
08/28/18
09/04/18
09/05/18
09/11/18
09/12/18
Client #6's file contained group notes that did not have documentation of a plan on the following dates:
07/10/18
07/11/18
07/23/18
07/24/18
07/25/18
07/30/18
08/06//18
08/14/18
08/21/18
08/27/18
08/28/18
09/04/18
09/05/18
09/11/18
09/12/18
Client #7's file contained group notes that did not have documentation of a plan on the following dates:
07/10/18
07/11/18
07/16/18
07/23/18
07/24/18
07/25/18
07/30/18
08/14/18
08/16/18
08/21/18
08/27/18
08/28/18
09/04/18
09/05/18
09/11/18
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
The Director of Residential Services shall review and update the Electronic Record format to ensure the inclusion of Plan statements on Group Progress Notes.
Responsible Person-Director of Residential Services Completion Date 12/1/18
Clinical Supervisors will provide in-service training on documentation of group progress notes
Responsible Person-Clinical Supervisor Completion Date 12/15/18
Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate inclusion of plan on group progress notes.
Responsible Person- Clinical supervisor Completion Date 2/15/19
the clinical supervisor will review all active clients to assure that DAP format is utilized and documented if it is not completed the therapist will make note adjustments to meet the DAP requirements.
Responsible Person-Clinical Supervisor Completion Date 12/01/18
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the facility's staffing report. The facility failed to document a written training plan for each employee.
A review of the facility's Staffing Requirement Facility Summary report revealed that a current training plan was not available for employee #6.
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Plan of Correction
clinical supervisor will meet with employee number# and complete their training plan
responsible -clinical supervisor
date of completion 11/1/2018
The clinical supervisor will create a check sheet identifying all staff and monitor that Training plans are completed within 30 days of hire for new employees and by January 31, of each year for all other employees Responsible?Clinical Supervisor - Date of completion ---11-1-18
the clinical supervisor will meet with employee # 6 by 11/16/18 to complete their training plan
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