INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2018 through February 9, 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 DD/FIR was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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Plan of Correction
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual report. The 2016 annual report was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence for Bankruptcy NPHS will complete an annual report- the first report will cover FY 7-1-2017 thru 6-30-2018. The Sr. Vice President and CEO will ensure that annual reports are completed on or before September 30th of each year.
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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
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual audit. The 2016 annual audit was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence from Bankruptcy NPHS will complete its annual audit and file a copy with DDAP. The CEO/Sr. Vice President will ensure that the audit is done on an annual basis. |
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
Based on a review of 14 client records on February 6, 2018 through February 7, 2018, the facility failed to obtain a valid consent to release of information in four client records.
Client #8 was admitted on November 30, 2017. A medication letter was release on 12/6/17 without the name of the Dr. or agency with identifying information about the client.
Client #9 was admitted September 1, 2017. A consent to release to a medical facility dated September 8, 2017 was missing what was being release. Lastly, a progress note dated September 6, 2017, stated that communication was made with the client's mother, a treatment facility and the client's PO. No consent on file for either the mother, treatment facility or the client's PO.
Client #10 was admitted on September 29, 2017. There were four consents, one date October 26, 2017, another dated November 14, 2017 and two dated November 1, 2017, with identifying information about the client. Could not determine if consent were on file for the agency or person since the names were illegible.
Client #12 was admitted on October 30, 2016 and discharge on December 29, 2016. There were four consents all dated October 30, 2017 that failed to have the date the client signed the releases. Another consent for the client Dr. dated March 29, 2017 did not have on the consent; what was being release, whether the client was offered a copy of the consent, staff did not sign or date and when the release is to expired not documented. Additionally, there were three consents where the client signed and dated on 4/13/17 and staff signed and dated on 4/14/17 and there were no expiration date documented.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The training coordinator will provide two trainings focusing on the appropriate way to complete a consent to release form. This training will also include identifying specific contacts that require a consent to release information, as well as what information that may be released to various agencies and individuals. |
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
Based on a review of client records on February 6-7, 2018, the facility failed to provided documentation of the client rights in client records, #8, 9, 10 and 11. The formed the clients signed only stated that the client had a right to review their record.
Client #8 was admitted on November 30, 2017
Client #9 was admitted on September 1, 2017
Client #10 was admitted on September 29, 2017
Client #11 was admitted on December 14, 2017
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical director will update the client's bills of rights to include verbiage ""clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records". |
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of three discharge detox client records on February 6-7, 2018, the facility failed to document an aftercare paln in client records, #6 and 7.
Client #6 was admitted on December 16, 2016 and discharged on December 21, 2016.
Client #7 was admitted on May 14, 2017 and discharged on My 18, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the training coordinator will conduct a training on the requirements of developing a aftercare plan.The clinical supervisor will then conduct a monthly audit of 25% of the clients who have been discharged to assure that the all aftercare and follow procedures are completed. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of three discharge detox client records on February 6-7, 2018, the facility failed to document a follow-up in client records, #6 and 7.
Client #6 was admitted on December 16, 2016 and discharged on December 21, 2016.
Client #7 was admitted on May 14, 2017 and discharged on My 18, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will conduct a monthly audit of 25% of the clients who have been discharged to assure that the all follow procedures are completed. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven rehabilitation client records on February 6-7, 2018, the facility failed to ensure that all clients signed a consent to treatment.
Client #14 was admitted to DD/Fir on April 26, 2017 and discharged on January 2, 2018. The consent to treatment documented in the client's records was for another licensed facility under the project.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the clinical director will conduct a training with the intake staff covering the location and license number of all the programs located at north Philadelphia health system. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of seven rehabilitation records on February 6-7, 2018, the facility failed to document a psychosocial evaluation in client records, #9, 13 and 14. Additionally, the facility failed to evaluate the client, facility staff only documented what the client reported in record, #11.
Client #9 was admitted on September 1, 2017
Client #11 was admitted on December 14, 2017
Client #13 was admitted on April 28, 2017 and discharged on July 31, 2017.
Client #14 was admitted on April 26, 2017 and discharged on January 2, 2018.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the clinical supervisor will complete a weekly chart audit to assure that all required admission documents are competed on new clients this will begin on 4/2/2018. in addition The clinical supervisor will conduct an assessment and identify all clinicians who struggle with writing an evaluative evaluation. Once these individuals are identified they will attend assessment and clinical formulation training provided by CBH network development department. This target date is 6/20/2018
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of seven rehabilitation client records on February 6-7, 2018, the facility failed to document a complete comprehensive treatment plan for the following clients:
Client #8 was admitted on November 30, 2017. The treatment plan was created on 11/30/17, but failed to have the client's signature and date.
Client #10 was admitted on September 29, 2017. The treatment plan was created on 11/3/17, but failed to have documentation of the frequency when it comes to individual and groups sessions.
Client #13 was admitted on April 28, 2017 and discharged on July 3, 2017. The treatment plan was created on 5/3/17, but failed to include type and frequency when it comes to individual/groups sessions and support services being offered to the client.
Client #14 was admitted on April 26, 2017 and discharged on January 2, 2018. The treatment plan was not signed or dated by the client until 6/29/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the clinical director with conduct an treatment plan training to included the following topics initial treatment plan, comprehensive treatment plan, treatment plan update,and type and frequency. also included in the training will be the need for client signature. the clinical supervisor will provide monthly supervision to each therapist where three random charts will be reviewed for treatment plan compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime 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 seven client records on February 6-7, 2018, the facility failed to document a treatment plan update in client records, #9, 10, 11 and 13.
Client #9 was admitted on September 1, 2017. The last treatment plan update was documented on October 9, 2017.
Client #10 was admitted on September 29, 2017. The facility failed to document an update to the client's stated goals in treatment plans, 11/4/17, 11/30/17, 1/2/18 and 2/2/18.
Client #11 was admitted on December 14, 2017. The comprehensive treatment plan was developed on December 19, 2017 and as of the date of the licensing inspection there was not documentation of a treatment plan update.
Client #13 was admitted on April 28, 2017 and discharged on July 31, 2017. The comprehensive treatment plan was developed on May 3, 2017 and the treatment plan was not documented until July 6, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the clinical director with conduct an treatment plan training to included the following topics initial treatment plan, comprehensive treatment plan, treatment plan update,and type and frequency. also included in the training will be the requirement for client signature. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of three rehabilitation discharge client records on February 6-7, 2018, the facility failed to document a complete client record in records, #12, 13 and 14.
Client #12 was admitted on October 30, 2016 and discharged on December 29, 2016. The facility failed to document a discharge summary, aftercare plan and follow-up.
Client #13 was admitted on April 28, 2017 and discharged on July 31, 2017. The facility failed to document a follow-up.
Client #14 was admitted on April 26, 2017 and discharged on January 2, 2018. The facility failed to document a discharge summary and aftercare plan.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will conduct a monthly audit of 25% of the clients who have been discharged to assure that the all discharge and follow procedures are completed. |