INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 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, IOP-Cap, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document that all staff members received an individual training plan.
Employee #6 was hired on November 8, 2007.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will create a check sheet identifying all staff and monitor that Training plans are completed within 30 days of hire for new employees and by January 31, of each year for all other employees.
Responsible: Clinical Supervisor
Date of completion: 11/01/2018
The clinical supervisor will develop a training plan for employee#7 on or before 11-20-18 |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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
The facility failed to keep the grounds free from any danger to health and safety.
The ground exit from the east fire tower had cracks in the sidewalk and a fence that was damaged which allows access to a ledge leading to a subterranean 'pit'. Additionally, an exit door, located on the second floor had a window with a hole in the glass with jagged edges presenting a safety hazard.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Landlord will completed repair of the exit, area and the broken window.
Responsible Party: IS3 Maintenance Department
Date of Completion: 11-15-18
Monthly rounds will be completed by the environmental services beginning immediately to insure that issues of this type are repaired in a timely manner and do not recur.
Results of rounds will be reported to the Sr. Vice President in monthly operations meetings.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection the facility failed to keep the grounds free from any danger to health and safety.
There were rodent droppings on the floor along the wall in room 302, which was a counselor's office.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
NPHS Environmental Services Department will clean the area immediately and conduct weekly rounds to insure that that the area is clean and free of droppings.
Date: Immediately 10/20/18
The Environmental Services director will ensure regular treatment of the area by pest control and ensure the condition does not recur.
Completion Date: Beginning 10/20/18 & ongoing indefinitely
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection the facility failed to ventilate each bathroom.
The rear bathroom located on the third floor, in the common lounge area did not have a functioning ventilation system.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The NPHS Maintenance Department will repair all exhaust motors in the bathrooms and repair the windows so that they are operational. Maintenance Department will monitor on a monthly basis during environmental rounds.
Responsible Party: Director of Facilities Management Completion Date: 11-30-18
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705.24 (6) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on the physical plant inspection the facility failed to provide all of the required elements in each bathroom.
The front bathroom located on the third floor, in the common lounge area did not have any toilet paper.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Environmental Services Department place toilet paper in the bathroom immediately.
The EVS department will increase the number of "passes" to this floor to insure that paper is always available.
The EVS department will monitor the availability of paper products on a daily basis indefinitely to insure this deficiency does not recur
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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
Based on an inspection of the facility's physical plant the facility failed to prohibit heaters that are not permanently mounted or installed.
There were portable heaters in room 309, which was a counselor's office and in room 327 which was a storage area.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Portable heaters will be removed immediately by staff.
Memo will be sent by clinical supervisor reinforcing policy regarding non-use of portable heaters- On or before October 31,2018
Clinical supervisor will monitor on a monthly basis to insure no portable heaters are use.-Ongoing |
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
Administrative documents were reviewed on September 4, 2018 through September 5, 2018. The facility failed to present the financial audit for fiscal year 2017.
The facility director confirmed the finding.
This is a repeat citation
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Plan of Correction
The CEO will request an exception to 709.25 based on NPHS recent Bankruptcy. Compliance with the financial audit requirement cannot be met until December 2019.
The CEO submitted request and received approval on 11-6-18. |
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 seven client records on September 12, 2018, the facility failed to document a valid consent to release information form for clients #1-7. The facility's consent template states that the consent may only be revoked by notifying the facility Medical Records Department. Additionally, all records reviewed contained a consent to release information to "The criminal justice system" that failed to identify the specific person or agency to whom information was to be released.
Client #1 was admitted on 4/19/18 and was an active client at the time of the licensing inspection.
Client #2 was admitted on 6/20/18 and was an active client at the time of the licensing inspection.
Client #3 was admitted on 7/19/18 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 4/6/18 and was discharged on 6/29/18.
Client #5 was admitted on 2/6/18 and was discharged on 7/25/18.
Client #6 was admitted on 4/6/18 and was discharged on 8/18/18.
Client #7 was admitted on 2/26/18 and was discharged on 9/5/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Sr. Vice President of Behavioral Services will review and update all consents to release information removing references to the Medical Records Department and indicating that consent can be withdrawn by giving verbal or written consent to any clinical staff member
Responsible Person: Senior VP
Completion Date: 10/31/18
Clinical Supervisor will review all consents to release information to "The criminal justice system" for active clients and ensure that missing information is documented including specific person or agency to whom information will be released.
Responsible Person: Clinical Supervisor of IOP/CAP
Completion Date: 10/31/2018 |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Seven client records were reviewed on September 12, 2018. The facility failed to document a consent to treatment for clients #1-7.
Client #1 was admitted on 4/19/18 and was an active client at the time of the licensing inspection.
Client #2 was admitted on 6/20/18 and was an active client at the time of the licensing inspection.
Client #3 was admitted on 7/19/18 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 4/6/18 and was discharged on 6/29/18.
Client #5 was admitted on 2/6/18 and was discharged on 7/25/18.
Client #6 was admitted on 4/6/18 and was discharged on 8/18/18.
Client #7 was admitted on 2/26/18 and was discharged on 9/5/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will provide in-service training to all staff regarding the proper completion of consents, training will include all aspects of the consent including the requirement to offer a copy of the form and document the offer.
Responsible Party: Clinical Supervisor
Completion Date: 01/15/2019
The counselors will review all active cases and update the charts with valid consent forms by 11/30/18 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven client records were reviewed on September 12, 2018. The facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluation statement and recommendations in records, #1-4 & 6-7.
Psychosocial evaluation for client #1 was documented on 4/23/18.
Psychosocial evaluation for client #2 was documented on 6/22/18.
Psychosocial evaluation for client #3 was documented on 7/24/18.
Psychosocial evaluation for client #4 was documented on 4/20/18
Psychosocial evaluation for client #6 was documented on 4/4/18
Psychosocial evaluation for client #7 was documented on 2/26/18
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will provide in-service for all counselors on case conceptualization.
In addition, Clinical Supervisor will ensure that all counselors are scheduled for CBH Assessment Module Training which includes assessment.
The clinical supervisor will review all active cases and insure that assessment is completed on or before 11/30/18
The clinical Supervisor will monitor charts on a monthly basis to insure this citation does not recur.
Responsible Party: Clinical Supervisor
Completion Date: 01/15/2019 |
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
The facility failed to update treatment plans every 60 days in two of five client records.
Client #5 was admitted on 2/6/18 and was discharged on 7/25/18. A treatment plan update was documented on 4/17/18; a treatment plan update was due by 6/17/18 but was not documented at the time of the inspection.
Client #6 was admitted on 4/6/18 and was discharged on 8/18/18. A comprehensive treatment plan was documented on 4/6/18; a treatment plan update was due by 6/6/18 but was not documented until 6/14/18. Additionally, another update was due by 8/14/18 but was not documented at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will provide in-service for all counselors on Treatment Plan policy and procedure.
In addition, Clinical Supervisor will ensure that all counselors are scheduled for CBH Assessment Module Training which includes treatment planning.
The clinical supervisor will monitor records on a monthly basis to insure that treatment plans are updated in a timely fashion and that this citation does not recur.
Responsible Party: Clinical Supervisor
Completion Date: 10/31/2018 |