INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 14, 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, Goldman Clinic, 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.
|
Plan of Correction
|
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.
|
Observations
A review of personnel records revealed that the facility failed to complete an annual individual training plan for three staff members. Annual training plans were not completed for employees #4, #7 and #8.
The last training plans were completed January of 2017.
The findings were reviewed with staff during the licensing inspection.
|
Plan of Correction
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 ---12-1-18
The clinical supervisor will complete a training plan on employee #4, 7, 8
Responsible: clinical supervisor
Date of completion: 12/1/2018
|
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.
|
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.
|
Plan of Correction
IS3 (Ironstone) the Landlord will completed repair of the exit, area and the broken window.
Responsible Party: IS3 Maintenance Department Date of Completion: 11-15-18
Fire safety director will conduct monthly rounds to assure that the environment is safe. He will then report his findings to the VP of behavioral health and IS3 ( ironstone ) to have repairs completed
|
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection the facility failed to keep the facility free from hazards.
The 7th floor exit into the east fire tower was full of dryer lint that was being exhausted into the fire tower from the laundry room. This lint creates a potential safety hazard.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
NPHS Maintenance Department will clean the fire exit and connect exhaust so that it does not blow lint into the fire Tower.
Responsible Party: Facility Director Completion Date: Immediately 10/20/18
Fire safety director will conduct monthly rounds to assure that the environment is safe. He will then report his findings to the VP of behavioral health and IS3 ( ironstone ) to have repairs completed. this will begin 12/1/2018
|
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
Based on the physical plant inspection the facility failed to provide all of the required elements in each bathroom.
The bathroom located in room #723 on the 7th floor did not have any paper towels or a mechanical dryer.
The findings was discussed with facility staff during the licensing inspection.
|
Plan of Correction
The Sr. Vice President will review the housekeeping performance guidelines with the Director of Housekeeping regarding cleaning and stocking bathrooms-Responsible Party SrVP-Completion October 1, 2018
Support staff will monitor bathrooms during daily environmental rounds to insure paper products are available and will report any problems immediately to the housekeeping department.
Responsible Party-ARA's MHW's and CRS?Ongoing Monitoring-Date of completion 12-31-18
|
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection, the facility failed to properly ventilate all toilet and wash rooms.
The following rooms on the 9th floor had exhaust fans that were non-functioning:
The bathroom across from the fire exit.
Room 908
Room 902
Room 904
In addition, room 903 did not have an exhaust fan in the lavatory and the window wouldn't open.
|
Plan of Correction
The NPHS Maintenance Department will repair all exhaust motors in the bathrooms and repair the windows so that they are operational. Maintenance Department will monitor on a monthly basis during environmental rounds.
Responsible Party: Director of Facilities Management Completion Date: 11-30-18
|
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
|
Observations
Based on a physical plant inspection, the facility failed to provide sanitary tissue in each lavatory at all times.
The bathroom located in room #716 on the 7th floor did not have sanitary tissue in the 1st and 2nd bathroom stalls.
The bathroom located in room # 906 on the 9th floor did not have sanitary tissue.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
The Sr. Vice President will review the housekeeping performance guidelines with the Director of Housekeeping regarding cleaning and stocking bathrooms-Responsible Party SrVP-Completion October 1, 2018
Support staff will monitor bathrooms during daily environmental rounds to insure paper products are available and will report any problems immediately to the housekeeping department.
Responsible Party-ARA's MHW's and CRS?Ongoing Monitoring-Date of completion 12-31-18
|
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.
|
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
|
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
The exception was submitted and approved on 11/9/2018 |
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
Seven client records were reviewed on September 14, 2018; the facility failed to document a valid consent to release information for clients 1-7. The facility's consent template states that the consent may only be revoked by notifying the facility's Medical Records Department. Additionally, the following issues with individual consents were identified:
Client #1 admitted 4/16/18 and discharged 5/14/18 had a consent to release information to an agency, dated 4/16/18, that did not identify the purpose of the information to be released. Additionally, a consent to release information to a government agency, dated 4/16/18, that was not signed or dated by the client or staff member.
Client #2 admitted 4/23/18 and discharged 6/22/18 had a consent to release information to an agency, dated 4/23/18, that did not identify the purpose of the release or the information to be released. Additionally, a consent to release information to a government agency, dated 4/23/18, that did not identify the purpose of the information to be released. There was also a letter to an agency, dated 4/23/18, but no consent to release information to this agency was documented.
Client #3 admitted 6/15/18 and discharged 8/9/18 had a consent to release information, dated 8/1/18, that did not identify the person or agency to whom the information was to be released. Additionally, a consent to release information to a government agency, dated 6/19/18, that did not identify the purpose of the information to be released, and another consent to release information to a government agency, dated 6/15/18, that did not identify the purpose of the information to be released.
Client #4 admitted 7/1/18 and discharged on 9/12/18.
Client #5 admitted 7/21/18 had a consent to release information, dated 7/20/18, that did not identify the person or agency to whom the information was to be released, or specify the purpose of the release. Additionally, a consent to release information to a government agency, dated 7/20/18, that did not identify the purpose of the information to be released.
Client #6 admitted 8/21/18. There was no consent to release information to the client ' s funding source documented in the record.
Client #7 admitted 9/7/18.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
The Sr. Vice President of Behavioral Services will review and update all consents to release information removing references to the Medical Records Department and indicating that consent can be withdrawn by giving verbal or written consent to any clinical staff member.
Responsible Person; SrVP Completion Date 10/31/18
clinical educator will provide training of all clinical staff members on appropriate ways to complete consent, and releases of information. new admission packets will developed through the electronic medical record system which includes consents and releases of information.
the facility will review the charts of all current clients to assure that hey are valid and contain all required elements by 11/16/2018
Responsible person: clinical educator
completion date 12/31/2018
|
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.
|
Observations
Seven client records were reviewed on September 14, 2018; the facility failed to document whether the client was offered a copy of the consent to release information for clients 1-5.
Client #1 admitted 4/16/18 and discharged 5/14/18.
Consent to release information to an agency, dated 4/16/18.
Consent to release information to a government agency, dated 4/16/18.
Client #2 admitted 4/23/18 and discharged 6/22/18.
Three consents to release information to an agency, and a government agency, and a funding source, all dated 4/23/18.
Client #3 admitted 6/15/18 and discharged 8/9/18.
Three consents to release information to an agency, and a government agency, and a funding source, all dated 6/15/18.
Client #4 admitted 7/1/18 and discharged on 9/12/18.
Two consents to release information to two persons, both dated 7/17/18.
Client #5 admitted 7/21/18.
Three consents to release information to an agency, and a government agency, and a funding source, all dated 7/20/18.
This information was reviewed with the facility staff during the licensing inspection.
|
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 including the requirement to offer a copy of the form and document the offer.
Responsible Party: Clinical Supervisor Completion Date 1/15/19
the clinical supervisor will review the charts of all current clients to assure that hey are valid and contain all required elements by 11/16/2018 |
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.
|
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 4/16/18 and discharged 5/14/18 did not have any documentation in the client record that the client was informed of their rights.
Client #2 admitted 4/23/18 and discharged 6/22/18 did not have any documentation in the client record that the client was informed of their rights.
Client #3 admitted 6/15/18 and discharged 8/9/18 did not have any documentation in the client record that the client was informed of their rights.
Client #4 admitted 7/1/18 and discharged on 9/12/18 did not have any documentation in the client record that the client was informed of their rights.
Client #5 admitted 7/21/18 did not have any documentation in the client record that the client was informed of their rights.
Client #6 admitted 8/21/18 did not have any documentation in the client record that the client was informed of their rights.
Clients #7 admitted 9/7/18 did not have any documentation in the client record that the client was informed of their rights.
This information was reviewed with the facility staff during the licensing inspection
|
Plan of Correction
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
|
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.
|
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:
4/17/18
4/20/18
4/26/18
4/24/18
4/25/18
4/30/18
5/2/18
5/3/18
5/7/18
5/11/18
Client #2's file contained group notes that did not have documentation of a plan on the following dates:
4/24/18
4/25/18
4/30/18
5/2/18
5/3/18
5/7/18
5/8/18
5/11/18
5/14/18
5/15/18
5/16/18
5/18/18
5/21/18
5/22/18
5/23/18
5/30/18
6/1/18
6/4/18
6/5/18
6/6/18
6/12/18
6/18/18
6/19/18
6/20/18
Client #3's file contained group notes that did not have documentation of a plan on the following dates:
6/18/18
6/19/18
6/20/18
6/22/18
7/3/18
7/6/18
7/9/18
7/13/18
7/16/18
7/20/18
7/23/18
7/24/18
7/27/18
7/30/18
7/31/18
8/1/18
8/6/18
8/7/18
Client #4's file contained group notes that did not have documentation of a plan on the following dates:
7/2/18
7/3/18
7/9/18
7/10/18
7/12/18
7/13/18
7/17/18
7/19/18
7/20/18
7/23/18
7/24/18
7/26/18
7/27/18
7/30/18
7/31/18
8/6/18
8/7/18
8/13/18
8/15/18
8/16/18
8/17/18
8/20/18
8/21/18
8/24/18
8/27/18
8/28/18
8/30/18
8/31/18
9/6/18
9/7/18
9/9/18
9/10/18
9/11/18
Client #5's file contained group notes that did not have documentation of a plan on the following dates:
7/26/18
7/27/18
7/31/18
8/6/18
8/7/18
8/9/18
8/15/18
8/16/18
8/17/18
8/21/18
8/23/18
8/27/18
8/28/18
8/30/18
8/31/18
9/4/18
9/6/18
9/7/18
9/10/18
9/11/18
Client #6's file contained group notes that did not have documentation of a plan on the following dates:
8/23/18
8/24/18
8/27/18
8/28/18
8/30/18
9/4/18
9/6/18
9/7/18
Client #7's file contained group notes that did not have documentation of a plan on the following dates:
9/10/18
9/11/18
This information was reviewed with the facility staff during the licensing inspection
|
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 11/1/18
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
|