INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 22, 2021 through September 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System - Goldman Clinic 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:
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Plan of Correction
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705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on an administrative review of the August 2020 through August 2021 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions for the months of November 2020, March 2021, May 2021, and June 2021. The fire drill logs for the months listed indicated that the fire drills were conducted outside of the facility's posted operating hours of Monday through Sunday from 6:00am to 2:30pm.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Goldman Clinic will ensure that fire drills are conducted monthly per DDAP regulation during clinic hours. The director of security will ensure that monthly drills are completed by scheduling drills on a monthly basis. The Executive Director will follow up with security to ensure compliance. |
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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in six of eight client records reviewed.
Client # 1 was admitted on September 1, 2017 and was still active at the time of inspection. The release of information form to the funding source was signed by the client and witness on December 13, 2019 and the form expired on December 13, 2020. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after December 13, 2020.
Client # 2 was admitted on October 24, 2019 and discharged on June 29, 2021. There was evidence of disclosures to the funding source during the treatment episode; however, there was no consent to release information documented in the record prior to the disclosure.
Client # 3 was admitted on February 6, 2020 and was discharged on July 28, 2021. The release of information form to the funding source was signed by the client and witness on February 6, 2020 and the form expired on February 6, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after February 6, 2021.
Client # 4 was admitted on January 25, 2019 and was discharged on June 9, 2021. The release of information form to the funding source was signed by the client and witness on November 5, 2019 and the form expired on November 5, 2020. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after November 5, 2020.
Client # 7 was admitted on November 13, 2018 and was still active at the time of inspection. The release of information form to the funding source was signed by the client and witness on January 3, 2020 and the form expired on January 3, 2021. A new release of information form to the funding source was signed by the client and witness on September 23, 2021. However, there was evidence of disclosures to the funding source between January 3, 2021, when the first release form expired, and September 23, 2021, when the new release form was signed.
Client # 8 was admitted on July 2, 2019 and was discharged on May 21, 2021. The release of information form to the funding source was signed by the client and witness on July 2, 2019 and the form expired on July 2, 2020. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after July 2, 2020.
This is a repeat citation from the May 4, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Goldman Clinic has implemented new consent forms which expire 60 days after discharge. All participants with existing consents on the old forms will be provided with new consent forms to sign. Clinical supervisors will ensure that all consents are updated and signed by participants in quarterly chart reviews. The Executive Director assigns randomly, chart to review on a monthly basis and will review chart audits to ensure compliance. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in two of eight patient records reviewed.
Patient # 1 was admitted on September 1, 2017 and was still active at the time of inspection. There was no documented drug screen urinalysis, in the record, for the month of May 2021.
Patient # 3 was admitted on February 6, 2021 and was discharged on July 28, 2021. There was no documented drug screen urinalysis, in the record, for the month of June 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Clinic will ensure that participants receive random urine drug screens on a monthly basis. Counselor will be responsible to track urine drug screens to ensure that we are in compliance. Urine drug screens are randomly selected by Avatar system. If the system does not select a participant for a urine drug screen, the counselor will be responsible to enter the selection manually. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in one of two applicable patient records reviewed.
Patient # 6 was admitted on June 22, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of July 2021, there were zero minutes of psychotherapy provided to the patient. Additionally, during the month of August 2021, the record of service and progress notes documented that there was only 1 hour and 45 minutes of psychotherapy provided to the patient.
This is a repeat citation from the May 4, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Clinic counselor will be responsible to ensure that participants receive psychotherapy sessions per DDAP regulations. Participants who missed scheduled sessions will be placed on hold to ensure that they are seen. Clinical Supervisors will monitor to ensure compliance. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide at least 1 hour per month of group or individual psychotherapy per month during the third and fourth year of treatment in one of five applicable patient records reviewed.
Patient # 7 was admitted on November 13, 2018 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of August 2021, there was only 15 minutes of psychotherapy provided to the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Clinic counselor will be responsible to ensure that participants receive psychotherapy sessions per DDAP regulations. Participants who missed scheduled sessions will be placed on hold to ensure that they are seen. Clinical Supervisors will monitor to ensure compliance. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.
Patient # 6 was transferred in and admitted on June 22, 2021 and was still active at the time of inspection. The record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A brief in service will be conducted with Goldman Clinic staff on September 30, 2021 to review requirements for patient transfers. Counselors will be required to ensure that referring programs will receive verification of enrollment and dose per DDAP regulation. Clinical supervisors will be required to follow up with counselors to ensure this requirement is adhered too. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in one of six applicable patient records reviewed.
Patient # 3 was admitted on February 6, 2020 and was discharged on July 28, 2021. An annual physical examination was due by February 6, 2021; however, there was no annual physical examination given by the narcotic treatment program documented in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager will track annual exams that are due and schedule them one month prior to the due date to ensure that all annual exams are completed and submitted timely. Participants will be notified of their appointment date and hold will be placed on them the date of their appointment. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain a complete patient record, which is to include follow-up information regarding the patient, in two of four applicable patient records reviewed.
Patient # 3 was admitted on February 6, 2020 and was discharged on July 28, 2021. There was no follow-up information regarding the patient documented in the record at the time of the inspection.
Patient # 8 was admitted on July 2, 2019 and was discharged on May 21, 2021. There was no follow-up information regarding the patient documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Community Recovery Specialist will ensure that post discharge follow up letters are sent out to participants post discharge. The case manager will also complete post discharge follow up by placing phone calls to all participants 7 days post discharge. The post discharge follow up data will be documented on a spread sheet and maintained by the case manager. The executive director will review the post discharge follow up list monthly to ensure that calls are made and attempts to make calls are documented. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in six of six applicable patient records reviewed.
Patient # 1 was admitted on September 1, 2017 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on August 31, 2021; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient # 2 was admitted on October 24, 2019 and was discharged on June 29, 2021. The annual evaluation of the patient's status was completed by the counselor on October 29, 2020; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient # 3 was admitted on February 6, 2020 and was discharged on July 28, 2021. The annual evaluation of the patient's status was completed by the counselor on March 12, 2021; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient # 4 was admitted on January 25, 2019 and was discharged on June 9, 2021. The annual evaluation of the patient's status was completed by the counselor on January 28, 2021; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient # 7 was admitted on November 13, 2018 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on December 18, 2020; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient # 8 was admitted on July 2, 2019 and was discharged on May 21, 2021. The annual evaluation of the patient's status was completed by the counselor on July 1, 2020; however, the evaluation was not reviewed, dated, and signed by the medical director.
This is a repeat citation from the May 4, 2021 and September 26, 2019 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective, September 27, 2021 Avatar was updated to route all annual evaluations to the medical director to be reviewed, signed and dated. Counselors will complete annual evaluations and route them for review and electronic signature by the medical director and/or attending physician. |