INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and narcotic treatment monitoring conducted on August 17, 2016 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 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Fourteen personnel files were reviewed on August 10, 2016 during the onsite inspection. The facility failed to ensure that all counselors met qualifications for the position of counselor. Employee # 3 did not have documentation of one year of clinical experience at the time of hire on November 9, 2015, and therefore was not qualified for the designation of counselor.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The plan of correction:
1 )Employee #3 will complete the required close supervision for 6 months under the supervision of the clinical supervisor. Supervisory notes will be documented and made available for future inspections. Will be completed by May 3, 2017.
2 ) Clinical Supervisor or any employee is hired, the Program Director will review all information provided to ensure that the candidate meets the clinical experience and degree requirements effective November 4 , 2016.
3) The Human Resource department will be responsible for verifying work history and degree effective November 4 , 2016.
3) After all information has been verified the Program Director and the Department of Human Services will make the final decision to hire effective November 4 , 2016.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records during the onsite inspection on August 10, 2016, the facility failed to document the completion of 12 clock hours of annual training required for the facility director. According to the record provided, the facility director earned a degree during the training year under review, however, the transcripts revealed that no classes were taken in that year. The personnel record contained a certificate for a training or program but offered no indication of the length of time of the training program. The training year reviewed was January 1, 2015 through January 31, 2015.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1 )To ensure that this deficiency will not recur all certificates will be reviewed upon the completion of any trainings to ensure that the dates and hours are documented. If they are not and a new certificate cannot be generated indicating the dates and hours, then documentation such as a syllabus or roster that would indicate the courses, dates and times will be kept with the certificate so that verification is available.
2)Facility will request a documentation such as a syllabus or roster from Bryn Mawr College's Nonprofit Executive Leadership Institute that would indicate the courses, dates and times of NELI training.
3) The Facility will contact Bryn Mawr College's Nonprofit Executive Leadership Institute for documentation of continuing education hours for the seminars listed below :
Session I
Individual Leadership Styles and
Impact on Team Development
Leading Systemic Change
Connecting With Your Learning Communities
Session II
Managing Diversity and Inclusion
Strategic Thinking
Assessing Opportunities for Organizational Growth
Session III
Managing Group and Organizational Dynamics
Board Governance and Development
Public Speaking
Session V
Executive Coaching
Session VI
Effective Marketing
Legal and Ethical Issues For Leaders
Developing Your Leadership Pipeline
The sessions were held over a five month period in 2015 on the weekends . Upon receiving evidence of continuing education hours , the document will be placed project director's personal record.
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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
A physical plant inspection was conducted on August 17, 2016. Marred walls were observed throughout the building and there was chipped paint on the ceiling in the waiting area and on the walls of the dosing area.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of 14 personnel records during the onsite inspection on August 10, 2016, it was determined that the facility failed to ensure that all staff were instructed in the use of fire extinguishers upon employment. Employee # 2 had no record of fire extinguisher training. Employee #4, who was hired on April 13, 2015, had fire extinguisher training on June 28, 2016. Employee #14 was hired on February 8, 2016 and had no documentation of fire extinguisher training.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. North Philadelphia Health System's Human Resource department's oreintation monitor will oversee future employees attendance at fire extinguisher training and complete on time.Human Resource department will inform Goldman Clinic , if employee has missed fire extinguisher training. Clinic supervisor of the employee will reschedule the personnel for training and monitor attendance.
2.The two personnel who lacked documentation of fire exinguisher training will receieve instruction on the use of the fire extinguisher September 29,2016.
3.Documentation of attending and receiving instructs on the use of the fire extinguisher will be placed in their personnel records.
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
The physical plant inspection was conducted on August 16, 2016 and August 17, 2016. The facility's trash compactor outside of the kitchen was filled to the point that it was unable to to be closed, thus unable to to prevent the penetration of insects and rodents.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016.
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705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
A physical plant inspection was conducted on August 17, 2016. Cracked tiles were observed in a group counseling room.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
A physical plant inspection was conducted on August 17, 2016. The facility failed to ensure privacy so that counseling sessions could not be seen as a counseling session was being conducted in the clinical supervisor's office with the blinds open.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. In keeping with Standard # 705.23, all counseling sessions will be conducted with doors and window blinds closed to ensure the privacy and confidentiality of all participants.
2. To ensure privacy, supervisors will randomly inspect office doors and windows to make sure compliance is maintained.
3. Written reminders will also become part of treatment team meeting agendas September 26,2016.
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
A physical plant inspection was conducted on August 17, 2016. Tiles were missing, a baseboard was falling off and a handicap bar was loose in a client bathroom.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A physical plant inspection was conducted on August 17, 2016. Two heaters that were not permanently mounted or installed were observed in two counselor's offices.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016.
1 ) The portable heaters were removed from the two counselors offices on 09/28/2016.
2 )The facilities manager will check if any counselor or other staff are in need of a baseboard heater . Baseboard heaters will be installed where need to ensure that this does not recur. |
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 patient records on August 17, 2016 and August 18, 2016, the facility failed to obtain an informed and voluntary consent in the following patient records, #1, 2, 3, 6 and 7.
Patient #1 - The facility failed to document the date the patient signed the consent forms and the date the consents would expire in two consents. One dated 7/25/16 to a treatment provider and the other one dated 5/24/16 to the patient's funding source.
Patient #2 - The facility failed to document the date the patient signed a consent to release form to a lab dated 6/24/16. Additionally, the facility failed to document the name of the agency and the date the patient signed the consent to release form.
Patient #3 - A fax was sent out to an agency with patient identifying information on 6/15/16, the facility failed to have a consent to release on file for this agency. Additionally, during the review of the patient's progress notes it was reviewed that communication was made with the same agency listed above pertaining to the patient on 6/27/16 with no consent to release on file.
Patient #6 - The facility failed to document the date the staff signed the consent forms and the consent forms only had documented that the patient can only revoke in writing. The one consent was dated 1/4/16 and the other was dated 1/28/16.
Patient #7 - The facility failed to update the patient's consent to releases for the following agencies: two insurances companies, on lab, one to a hospital, one to a family member and one to a government agency. The date that was documented on the consent to release forms was 12/2/14, the consent to release forms are to be updated yearly.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility reviewed observations about patient records, #1, 2, 3, 6 and 7. related to informed and voluntary consent to prevent reoccurs:
1. Due to participants #6 & 7 have been discharged from treatment; therefore new consent to release information forms cannot be obtained from them. Consent forms will be revised to reflect that consents may be revoked both verbally and in writing.Patient# 1 , 2 and 3 will meet their assigned counselor to review consents and update forms as needed.
2.All facility staff will document the date a participant signed the consent forms. Staff will monitor and assist participants when needed with documenting date of their consent signing.
3.All facility staff will ensure that all consent forms fields are complete prior to transmitting information to an individual/or agency. All facility staff will document in progress notes related to consent forms process with participant.
4 All facility staff will at the time of a participant's annual evaluation review all consent forms. Consent forms needing updating will be review with participant for continuation of release of information and signature. New authorization for the release of information are signed by participant at their annual evaluation .
5.Clinical supervisor will review and monitor staff's ability to abide this correction action ,and 4 PA Code 255.5 and 42 CFR part 2 during monthly supervision.
6. A in-service on 4 PA Code 255.5 and 42 CFR part 2 will be performed on 9/26/2016 |
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.
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Observations
Based on a review of patient records on August 17, 2016 and August 18, 2016, the facility failed to ensure that the patient was offered a copy in the following patient records, #2, 5, 6, 7 and 8
Patient #2 - The facility failed to document that the patient was offered a copy of their consents for the following: insurance agency, case manager, government agency and a lab all consents were dated 6/24/16.
Patient #5 - The facility failed to document that the patient was offered a copy of their consent for a treatment provider dated 1/28/16.
Patient #6 - The facility failed to document that the patient was offered a copy of their consents for consent dated 1/28/16.
Patient #7 - The facility failed to document that the patient was offered a copy of their consents for the following: one to a treatment agency dated 8/18/15 and three consents to treatment facilities dated 12/11/15.
Patient #8 - The facility failed to document that the patient was offered a copy of their consents for the following: one to a treatment agency dated 11/30/15 and two to a family member for the following dates 10/13/15 and 11/3015.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility reviewed observations related patient not being offered a copy of their consent in the following patient records, #2, 5, 6, 7 and 8 to prevent reoccurrence.
1) Patient # 2 will meet with assigned counselor to review consents and update forms as needed. Upon completion of consents process counselor will provide a copy to participant.
2)Clients #5, 6, 7 & 8 have been discharged from treatment; therefore new consent to release information forms cannot be obtained from them.
3) All facility staff will abide by policy 711.93(4) procedures
4) Information released with a signed consent
5) The Clinician or employee presenting the release to the participant will sign as the witness and explain the Authorization for Release of Information form in detail to the participant. The participant is informed, in a manner that assures his/her understanding, the following:
6)The specific type of information that has been requested, as well as the benefits and disadvantages of releasing the information, if known.
7 )The name of the person, agency, organization to whom disclosure is to be made.
8)The purpose or need of the information.
9)That treatment services are not contingent upon the participant's decision concerning authorization for the release of information.
10)That he/she must give their consent freely and voluntarily.
11)The date the consent expires.
12)The participant consents, and signs and dates the Authorization for Release of Information form in the presence of the witness. The witness signs and dates the form.
13 )Signed Release of Information forms are filed in the participant's record. A copy is offered to the PARTICIPANT. Any disclosure is fully documented in the participant's chart.
14) The information released from the participant's record is limited to:
a. Whether that Participant is or is not in treatment
b. The prognosis of the Participant
c. The nature of the project
d. Brief description of the progress of the Participant
e. Short statement as to whether the participant relapsed into drug and/or alcohol abuse and frequency of use.
15 ) Clinical supervisor will review and monitor staff's ability to abide this correction action , and 4 PA Code 255.5 and 42 CFR part 2 during monthly supervision.
16) A in-service on 4 PA Code 255.5 ,42 CFR part 2 and Policy 711.93(4)will be performed on 9/26/2016
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of unusual incidents, the facility failed to notify DDAP within 3 business days of the unusual incident.
Incident report dated 2/3/16 - patient physically attacked a counselor.
Incident report dated 3/9/16 - patient physically attacked another patient.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Incident report dated 2/3/16 and incident report 3/9/16 will be re-faxed to DDAP.
1.The Facility will notify DDAP within 3 business days of any unusual incident and following Policy 715.28 procedures;
A. When program staff are informed of an unusual procedure or event, they are to document the incident and forward the incident report to a Clinical Supervisor, who in turn, will forward a copy of the unusual incident to the Hospital's Safety Officer.
B. A prompt review and investigation of the event shall be performed.
C.A timely and appropriate corrective action plan shall follow, when indicated.
D. There shall be an ongoing monitoring of the corrective action plan.
E.The program will file a written Unusual Incident Report with the Department of Health within 48 hr's following an unusual incident which may include the following:
1.Complaints of participant abuse (physical, verbal, sexual, or emotional).
2.Death or serious injury due to trauma, suicide, medication error, or unusual circumstances.
3.Significant disruption of services due to a disaster such as fire, storm, flood or other occurrence.
4.Incidents with potential for negative community reaction or which the facility
director believes may lead to community concern.
5.Drug related hospitalization of a participant.
The facility staff will provide Clinical Supervisor with a copy of the report being sent to the Program Director and Director of Safety who will monitor for Quality Assurance studies.
The unusual incident report is also filed with the Department of Health Health within 48 hr's of the event occurring.
Clinical supervisors will review Policy 715.28 will all staff on 9/29/2016, during supervision.
Clinical supervisor will monitor staff ability to follow Policy 715. 28 |
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.
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Observations
Based on a review of unusual incidents, the facility failed to notify DDAP within 3 business days of the unusual incident.
Incident report dated 1/2/16 - report of patient's death.
Incident report dated 1/14/16 - report of patient's death.
Incident report dated 2/14/16 - report of patient's death.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Facility will re-fax the three incident report to DDAP ,in conjunction if any unusual events occur :
The Facility will notify DDAP within 3 business days of any unusual incident and following Policy 715.28 procedures;
A. When program staff are informed of an unusual procedure or event, they are to document the incident and forward the incident report to a Clinical Supervisor, who in turn, will forward a copy of the unusual incident to the Hospital's Safety Officer.
B. A prompt review and investigation of the event shall be performed.
C.A timely and appropriate corrective action plan shall follow, when indicated.
D. There shall be an ongoing monitoring of the corrective action plan.
E.The program will file a written Unusual Incident Report with the Department of Health within 48 hr's following an unusual incident which may include the following:
1.Complaints of participant abuse (physical, verbal, sexual, or emotional).
2.Death or serious injury due to trauma, suicide, medication error, or unusual circumstances.
3.Significant disruption of services due to a disaster such as fire, storm, flood or other occurrence.
4.Incidents with potential for negative community reaction or which the facility
director believes may lead to community concern.
5.Drug related hospitalization of a participant.
The facility staff will provide Clinical Supervisor with a copy of the report being sent to the Program Director and Director of Safety who will monitor for Quality Assurance studies.
The unusual incident report is also filed with the Department of Health Health within 48 hr's of the event occurring.
Clinical supervisors will review Policy 715.28 will all staff on 9/29/2016, during supervision.
Clinical supervisor will monitor staff ability to follow Policy 715. 28 |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incidents, the facility failed to notify DDAP within 3 business days of the unusual incident.
Twenty eight unusual incident reports showed documentation that 911 or EMS services were present on facility premises. Those unusual report dates ranged from September 2015 through August 2016.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility will notify DDAP within 3 business days of any unusual incident and following Policy 715.28 procedures;
A. Facility will forward copies of the 28 unusual incident reports to the Department of Drug and Alcohol Programs by November 10, 2017.
B. When program staff are informed of an unusual procedure or event, they are to document the incident and forward the incident report to a Clinical Supervisor, who in turn, will forward a copy of the unusual incident to the Hospital's Safety Officer.
C. A prompt review and investigation of the event shall be performed.
D. A timely and appropriate corrective action plan shall follow, when indicated.
F. There shall be an ongoing monitoring of the corrective action plan.
E.The program will file a written Unusual Incident Report with the Department of Health within 48 hr's following an unusual incident which may include the following:
1.Complaints of participant abuse (physical, verbal, sexual, or emotional).
2.Death or serious injury due to trauma, suicide, medication error, or unusual circumstances.
3.Significant disruption of services due to a disaster such as fire, storm, flood or other occurrence.
4.Incidents with potential for negative community reaction or which the facility
director believes may lead to community concern.
5.Drug related hospitalization of a participant.
The facility staff will provide Clinical Supervisor with a copy of the report being sent to the Program Director and Director of Safety who will monitor for Quality Assurance studies.
The unusual incident report is also filed with the Department of Health Health within 48 hr's of the event occurring.
Clinical supervisors will review Policy 715.28 will all staff on 9/29/2016, during supervision.
Clinical supervisor will monitor staff ability to follow Policy 715. 28
All outstanding incident reports will be submitted by November 10, 2016.
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715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
Based on a review of administrative paperwork on August 9-12, 2016 and August 15-18, 2016, the facility failed to have an updated Clinical Laboratory Permit from the Pennsylvania Department of Health. The permit reviewed expired August 15, 2016.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will display a updated certificate accreditation for Atlantic Diagnostic Laboratories LLC the expiration date is 07/22/2017. The permit was posted on 9/3/2016.
Clinical coordinator will monitor all permits for expiration dates and update as needed
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of client records on August 17, 2016 and August 18, 2016, the facility failed to ensure that the transferring facility transferred the required paperwork for patient #4.
Patient #4 was admitted on April 28, 2016 and as of the date of the licensing inspection no transferring documentation was documented in patient's record reviewed.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1)The facility will ensure that the transferring facility transferred the required paperwork by following the procedures listed below :
1. The participant must sign a release form authorizing the Release of Confidential Information to the receiving clinic and approval for follow-up contact.
2.The Primary Counselor will secure the following materials from the chart and send to the receiving MAT: admission date, medical and psychosocial summaries, current status report, dosage level, urinalysis reports (last six months), exception requests and the client's signed consent.
3.The Project shall secure written approval of acceptance from receiving project prior to transfer.
4.The receiving MAT shall confirm, in writing, actual receipt of the participant's file and arrival of the participant, and date of initial dose given to the participant by the receiving program.
5.The transferring program shall document what materials were sent to the receiving program in
the participant's record.
6.The transferring program shall maintain the confidentiality of participant's records remaining in it's possession after the transfer under Standard 715.11 (relating to confidentiality of Participant's records).
Clinical supervisors will monitor staff's ability to follow participant transfer procedures.
Clinical supervisors will perform a in-services on participant transfer during treatment team meeting on 9/30/2016
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records on August 17, 2016 and August 18, 2016, the facility failed to document a physical examination in patient records, #3 and 4.
Patient #3 was admitted on January 20, 2016. The facility failed to document a physical examination as of the date of the licensing inspection.
Patient #4 was admitted on April 28, 2016. The facility failed to document a physical examination as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1)The patients #3 & 4 have had physicals completed.
2)Patient # 3 physical was completed on 1/20/16 , copy can be scanned and forward to DOH. Next physical due 1/17.
3) Patient # 4 physical was completed on 4/29/16 , copy can be scanned and forward to DOH.Next physical due 4/17.
4 )Staff physicians and CRNP's are responsible for the completion of admission physicals. In- service review will be provided during the medical staff meeting on 9-21-16 and the nurse manager and program clinical supervisors will be responsible for monitoring the completion of physicals within program guidelines. Full compliance will be reached by 9/30/16
All active cases will have a physical examination completed and documented by November 20, 2016 |
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
Client #7 was admitted on December 2, 2014 and their annual evaluation was due by December 2, 2015. The facility failed to document client #7's annual evaluation as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address the facility failure to conduct an annual evaluation:
1 ) Patient #7 was discharged; therefore the facility cannot conduct an update for that patient. Moving forward the facility will conduct annual evaluations for all patients when required.
2) All counselors will complete an
annual evaluation documenting an
participant's employment, education and training , legal standing ,substance abuse history ,ability to manage financial matters ,physical and emotional health,fulfillment of treatment objectives and family and community supports status. Participants
annual evaluations will be completed on their admission's anniversary date.
3) Clinical supervisors will review
annual evaluations prior to the
medical director to determine if
participant's status was fully
documented .
4) The Medical Director will review,
date and sign annual evaluation .
5) Annual evaluations will be placed in
the participants' charts , after the
Medical Director review , date and
sign documents.
6) Clinical supervisors will be
responsible for implementing and
monitoring compliance to this plan effective 11/30/2016
7)An annual evaluation will be completed on the active case within 30 days. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of patient records on August 17, 2016 and August 18, 2016, the facility failed to document a preliminary treatment plan in patient records, #1, 2, 4 and 5.
Patient #1 was admitted on May 25, 2016. The comprehensive treatment plan was developed July 25, 2016.
Patient #2 was admitted on May 24, 2016. The comprehensive treatment plan was developed June 17, 2016.
Patient #4 was admitted on April 28, 2016. The comprehensive treatment plan was developed June 14, 2016.
Patient #5 was admitted on December 22, 2015 and discharged on February 9, 2016.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility will document a preliminary treatment plan on all patients admitted to Goldman.
1) The Program Physician completes an Initial Treatment Plan prior to the
first dose of methadone. It covers the participant in treatment for thirty days. This Initial Treatment Plan should be based upon information derived from the Initial Interview, Psychosocial History and other evaluations. This plan should also identify critical participant problems and strategies for their resolution.
2)Counselor will review initial treatment to develop comprehensive treatment plan with participant
3)Clinical supervisor will review all treatment plan for completion in a timely manner.
4)Clinical supervisor will perform a treatment plan in-service during treatment team meeting on 9/30/2016
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 patient records on August 17, 2016 and August 18, 2016, the facility failed to document a complete treatment plan in patient records, #1, 2, 3 and 5.
Patient #1 was admitted on May 25, 2016. The comprehensive treatment plan was developed July 25, 2016. The facility failed to document the comprehensive treatment plan during the intake process. Additionally, the facility failed to include on the treatment plan the type and frequency of services and support services.
Patient #2 was admitted on May 24, 2016. The comprehensive treatment plan was developed June 17, 2016. The facility failed to document that it was developed with the patient. Additionally, the facility failed to include on the treatment plan the type and frequency of services and support services.
Patient #3 was admitted on January 20, 2016. The comprehensive treatment plan was developed February 16, 2016. The facility failed to document that it was developed with the patient. Additionally, the facility failed to include on the treatment plan support services.
Patient #4 was admitted on April 28, 2016. The comprehensive treatment plan was developed June 14, 2016. The facility failed to document that it was developed with the patient. The counselor failed to sign and date the treatment plan. Additionally, the facility failed to include on the treatment plan the type and frequency of services and support services.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1 .Counselor's of patient # 1 , 2 , 3 and 5 will be counseled during supervision about the importance of completing treatment plan documentation.
2 ) The facility will document completion of comprehensive treatment plan completion with participant in the EHR Med-Host system.
3)Counselor will document completion of comprehensive treatment plan with participant in the EHR -Med-host system
4)The facility will review and revises treatment plan to include fields for
treatment plan the type and frequency of services and support services to be complete by counselor.
5)Clinical supervisors will monitor
staff's ability to complete all fields on revised treatment plan.
6)Clinical Supervisors will review revised treatment plan in team meeting on 10/24/2016
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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.
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Observations
Based on a review of patient records on August 17, 2016 and August 18, 2016, the facility failed to document a treatment plan update every 60 days in patient record, #3.
Patient #3 was admitted on January 20, 2016. The comprehensive treatment plan was developed February 16, 2016. The treatment plan updates were documented on April 18, 2016 and July 6, 2016.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1 .Counselor of patient # 3 will be counseled during supervision about the importance of completing treatment plan updates documentation within 60 day timeframe
2 ) Clinical supervisors will review Policy 711.92 Management of Treatment with counseling staff during treatment team meeting on 10/24/2016.
3 ) Clinical supervisors will monitor counselors' ability to abide by Policy 711.92 Management of Treatment procedures
4) Clinical supervisors will audit charts for compliance with comprehensive treatment plan completion time frame as stated in Policy 711.92 Management of Treatment
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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:
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Observations
Based on a review of patient records on August 17, 2016 and August 18, 2016, the facility failed to have a complete patient record in records, #2, 3, 4, 7 and 8.
Patient records #2, 3, 4 and 8 had case consultations documented, but the facility failed to document who all were part of those case consultations other than the counselor.
Patient #2 - case consultation date documented 7/26/16
Patient #3 - case consultation date documented 7/6/16
Patient #4 - case consultation date documented 7/29/16
Patient #8 - case consultation date documented 1/4/16
Additionally, the facility failed to document patient #7's discharge summary as of the date of the licensing inspection.
Patient #7 was discharged 2/2/16
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselor's of patient # 2 , 3 ,4 and 8 will be counseled during supervision about the importance of recordkeeping and report writing focusing on case consultation, also :
The facility will ensure documentation of who participated in case consultations other than the counselor by :
1) Clinical supervisor will perform a in-service on the importance documenting who was apart case consultations other than the counselor during treatment team meeting on 9/30/2016.
2) Clinical supervisors will monitor counseling staff's ability to follow case consultation procedures.
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