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Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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SOUTHWEST NU-STOP PHILADELPHIA, INC.
5616 WOODLAND AVENUE
PHILADELPHIA, PA 19143

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Survey conducted on 03/10/2017

INITIAL COMMENTS
 
This report is a result of an on-site licensure renewal inspection conducted on March 10, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Southwest Nu-Stop Philadelphia, Inc. 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:
 
Plan of Correction

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.
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #9 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe. Employee #9 was hired as a counselor on 11/09/15 and was due to have the communicable disease trainings no later than 11/09/16. There was no documentation in the personnel file of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.



The findings were discussed with facility staff during the licensing process.
 
Plan of Correction
Human Resource Director will maintain a tracking log of 1) HIV and TB/STD mandatory training and specific date required; 2) all training hours for each employee.



Employee #9 will receive the required training at the first available training class not to exceed 90 days.



Human Resource Director will audit the education tracking bi-annually, to ensure all new hires receive the 6 hours HIV and 4 hour TB/STD training within the state required timeframe.



The Human Resource Director will report the status of HIV and TB/STD training for new hires to the Executive Management Team, bi-annually to ensure compliance


709.26 (b) (2)  LICENSURE Personnel management.

709.26. Personnel management. (b) The personnel records must include, but are not limited to: (2) Written verification of qualifying professional credentials.
Observations
Based on a review of personnel records on 03/10/17, the facility failed to ensure that personnel records contained documentation of verification of professional credentials in employee record #7, who was hired as a counselor on 06/20/16.



These findings were reviewed with facility staff during the licensing inspection.
 
Plan of Correction
Verification of professional credentials in employee #7 were placed in the employee's file 3/28/17.



Human Resource Director will request of all new hires that professional credentials be submitted prior to the start of employment.



Human Resource Director will complete a bi-annual self audit to ensure all required documents are submitted and in each employee file.



Human Resource Director will report findings bi-annually to the Executive Management Team




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.
Observations
Based on a review of client records, the facility failed to ensure that consent to release information forms contained all required information in client record #'s 1, 2, 3, 4, 5, 6, and 7.



Client #1 was admitted on 03/08/16 and was an active client at the time of the inspection. The record contained a consent to release information form signed and dated on 03/08/16 to the primary care physician, which did not include the name, agency, or organization to which the disclosure would be made.



Client #2 was admitted on 05/03/16 and was an active client at the time of the inspection. The record contained consent to release information forms signed and dated on 05/03/16 to the primary care physician and to the emergency contact, both of which did not include the name, agency, or organization to which the disclosure would be made. Additionally, the record contained a consent to release information form signed and dated 05/03/16, which did not include the name, agency, or organization to which the disclosure would be made or the purpose for disclosure.



Client #3 was admitted on 08/10/16 and was an active client at the time of inspection. The record contained consent to release information forms signed and dated on 08/15/16 and 8/24/16 to the primary care physician, which did not include the name, agency, or organization to which the disclosure would be made.



Client #4 was admitted on 08/15/16 and was discharged on 12/12/16. The record contained consent to release information forms signed and dated on 05/10/16 to the primary care physician and to the emergency contact, both of which did not include the name, agency, or organization to which the disclosure would be made.



Client #5 was admitted on 04/28/16 and was discharged on 09/08/16. The record contained a consent to release information form signed and dated on 04/28/16 to the primary care physician, which did not include the name, agency, or organization to which the disclosure would be made. Additionally, the record contained a consent to release information form signed and dated 04/28/16, which did not include the name, agency, or organization to which the disclosure would be made or the purpose for disclosure.



Client #6 was admitted on 01/23/17 and was discharged on 03/01/17. The record contained consent to release information forms signed and dated on 01/19/17 to the primary care physician and emergency contact, which did not include the name, agency, or organization to which the disclosure would be made.



Client #7 was admitted on 08/30/16 and was discharged on 02/01/17. The record contained a consent to release information form signed and dated on 08/30/16 to the primary care physician, which did not include the name, agency, or organization to which the disclosure would be made.



The findings were reviewed with facility staff during the licensing process.
 
Plan of Correction
On 3/13/17 the Director met with all clinical staff to review the deficiency with the voluntary consent form.



A training was conducted by the Director on 3/30/17 for all clinical staff on the correct completion of the voluntary consent to release information form; additional focus will be on the need to document a specific name, agency or organization to which the disclosure is to be made. Each clinical staff person will receive a copy of the power-point for reference.



Additionally, the Southwest Nu Stop confidentiality regulation will be reviewed as to the requirement that prior to any disclosure of member information, there must be a signed copy of the voluntary consent to release information form in the member's file.



Client # 1 completed new releases of information on 3/20/17 for the primary care physician with the name included on the release. The old release dated 3/8/16 was voided.



Client # 2 completed new releases of information on 3/20/17 for the primary care physician and emergency contact with the name of each included on the release. The old release dated 5/3/16 was voided. The release form dated 5/3/17 that did not identify the name, agency or organization was voided.



Client # 3 completed new releases of information on 3/20/17 for the primary care physician with the name included on the release. The old release dated 8/15/16 and 8/24/16 was voided.



The Clinical Supervisor will focus on this area through weekly chart reviews which are ongoing



The Director will randomly review charts monthly to ensure compliance

709.34 (c) (2)  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: (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
Observations
On March 10, 2017, it was discovered that since the previous licensing inspection the facility had one client death while he/she was an active client. The facility was notified of the death on December 6, 2016. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory timeframe for the death of the client.





These findings were reviewed with facility staff during the licensing process.
 
Plan of Correction
The Director reviewed 709.34 regulation and provided a handout of the regulation to all staff. The focus was specifically the requirement to complete a written unusual incident form for incidents identified in the regulation. The incident form was distributed to staff. Notification to the state must be made within 48 hours.



The clinical supervisor completed the unusual incident form for the death from overdose, (12/6/16) and submitted to the state office on 3/30/17.



The Director will revise current policy on unusual incident reporting no later than 4/30/17.



The Director will introduce the new policy 5/1/17. The director will maintain a file of unusual incidents and monitor quarterly.

709.92(b)  LICENSURE Treatment and rehabilitation services

709.92. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Observations
Based on a review of client records, client record #'s 1, 3, and 5 had treatment plan updates completed after the regulatory timeframe or were missing at the time of the inspection.



Client #1 was admitted on 03/08/16 and was an active client at the time of the inspection. A treatment plan update was completed on 12/02/16 and an update was due no later than 02/02/17. However, no additional treatment plan updates were completed prior to the inspection.



Client #3 was admitted on 08/10/16 and was an active client at the time of inspection. A treatment plan update was completed on 11/10/16 and an update was due no later than 01/10/17. However, the next treatment plan update was not completed until 03/10/17.



Client #5 was admitted on 04/28/16 and was discharged on 09/08/16. A treatment plan update was completed on 06/28/16 and an update was due no later than 08/28/16. However, no additional treatment plan updates were completed prior to discharge.





These findings were reviewed with facility staff during the licensing process.
 
Plan of Correction
On 3/13/17 the Director met with all clinicians that complete the Treatment Plan Updates to review the deficiency, specifically completion within required time frames and placed in the client record.



Training will be conducted by the Director on 3/30/17 for all clinicians who co-develops with the client a Treatment Plan Update specifically on content and required completion time frames.



Client #1 and #3 will have the treatment plans completed to bring the chart into compliance no later than 4/7/17



The Clinical Supervisor will audit charts weekly to ensure compliance with this regulation.



The Director will randomly review charts monthly to ensure compliance with this regulation


709.93(a)  LICENSURE Client records

709.93. 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:
Observations
Based on a review of client records, the facility failed to provide a complete client record for client #'s 4, 5, and 7.



Client #4 was admitted on 08/15/16 and was discharged on 12/12/16. The client record did not contain documentation of case consultation notes as of the date of the inspection.



Client #5 was admitted on 04/28/16 and was discharged on 09/08/16. The client record did not contain documentation of case consultation notes as of the date of the inspection.



Client #7 was admitted on 08/30/16 and was discharged on 02/01/17. The client record did not contain any documentation of case consultation notes or discharge summary as of the date of the inspection.





These findings were reviewed with facility staff during the licensing process.
 
Plan of Correction
On 3/13/17 the Director met with all clinicians that provide documentation in the client record to review the deficiency, specifically inclusion of all required documents.



Training will be conducted by the Director on 3/30/17 for all clinicians responsible for documenting in the client record.



Included in this training will be a listing of all required documents with a focus on completion of discharge summaries and case consultations within the required time frames for completion.



Discharge summary will be completed for Client # 7 no later than 4/7/17



The Clinical Supervisor will audit charts weekly to ensure compliance with this regulation.



The Director will randomly review charts monthly to ensure compliance with this regulation


 
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