INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, North Philadelphia Health System - Return Program 1&2 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to ensure that each clinical supervisor or lead counselor who has not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
Employee # 3 was hired as a clinical supervisor on October 22, 2018. There was no documentation of the 30-hour DDAP sponsored clinical supervision training, or a department approved clinical supervision training on file at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will be scheduled to attend the DDAP supervision session or its equivalent within 90 days.
The Director of Residential services will monitor attendance and insure that any additional promotions or hires have the appropriate prior experience or training. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct an unannounced fire drill for the months of October 2018 through January 2019, April 2019, June 2019 and July 2019. Additionally, the facility failed to identify on their fire drill log the amount of time it took for the evacuation, the exit route used, and the number of persons in the facility at the time of the drill for every fire drill conducted from February2019 to August 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Log was updated on 9/12/19 to include the amount of time it takes for evacuation, the exit route used and the number of persons in the facility at the time of the drill.
The new log will be fully implemented by 10/30/19.
The IS3 facility director is responsible for completing the log and the NPHS safety office is responsible for reviewing on a monthly basis.
The NPHS safety office will monitor the frequency of Fire drills to insure that they occur on a monthly basis.
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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
The facility failed to develop, and make available to the public, their 2018 annual report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No annual report for FY 2018 was completed because of the prior bankruptcy status of the institution.
The Sr. Vice President will complete and annual report for fiscal year ending June 30, 2019 by November 30, 2019.
Annual Report will be posted on the website by December 15, 2019
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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
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No audit was completed for FY2018 because of the prior bankruptcy status of the organization.
The CFO is responsible for obtaining an audit for FY2019 and has engage a company to complete the audit.
Anticipated date of audit completion: December 30, 2019
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of eight client records reviewed.
Client # 1 was admitted on August 7, 2019 and was active at the time of the inspection. There was documentation of a letter to a physician, that identified the client as a member of the drug and alcohol facility, dated September 11, 2019; however, there was no consent to release information form to the physician on file prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent form in one of eight client records.
Client # 6 was admitted on August 19, 2019 and was active at the time of the inspection. There were two consent to release information forms signed and dated by the client on August 27, 2019; however, both of the consent forms did not include the specific name of the person, agency or organization.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to include the specific information that was to be disclosed on a consent to release information form in one of eight client records.
Client # 4 was admitted on February 14, 2019 and was discharged on March 21, 2019. There were three consent to release information forms signed and dated by the client on February 15, 2019; however, all of the consent forms listed one of the items to be disclosed as "other", but did not include specification of what would be released.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on the consent form in one of eight client records.
Client # 4 was admitted on February 14, 2019 and was discharged on March 21, 2019. There were two consent to release information forms signed and dated by the client on February 15, 2019 and one consent to release information form signed and dated by the client of March 11, 2019; however, all of the consent forms listed "other" as the purpose of disclosure and did not provide specification of the purpose.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion
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709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide documentation verifying that each client record reviewed had given written acknowledgement that they were informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation that the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental if presented to the client.
All active Participants will be provided the new form to sign-copies will be placed in their records and they will be offered a copy of the form.
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
The clinical Supervisors of the program will be responsible for insuring that all currently active participants are provided with and sign the updated form.
Completion will be by 10/30/19
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to provide documentation that a client was notified, in writing, of the reason for the facility's decision to involuntarily terminate the client from treatment in two of three applicable client records reviewed.
Client # 5 was admitted on December 14, 2018 and was administratively discharged on January 10, 2019.
Client # 7 was admitted on July 1, 2019 and was administratively discharged on August 5, 2019.
The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Residential Services will review the Administrative Discharge policy with all of the clinical supervisors by 10/15/19.
Clinical Supervisors will review the policy with counseling and nursing staff by 10/30/19.
The clinical supervisors will log all administrative discharges for next 3 months to ensure that notification of intent is given to Participants.
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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
The facility failed to notify the Department within 3 days following an unusual incident, which involved a physical assault by a client occurring on August 5, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the policy regarding the reporting of Unusual Incidents to DDAP with the staff by November 1, 2019.
Copies of the Unusual Incident report form will be placed on the desk top of all clinicians and nursing stations for provide for easy access to the form.
The Clinical supervisor will perform a focus review for 60 days to be completed by December 31, 2019. Random ongoing review/monitoring will continue indefinitely thereafter.
Completion December 31, 2019
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