INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6-9, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System - Torre De La Raza was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility
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Plan of Correction
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual report. The 2016 annual report was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence for Bankruptcy NPHS will complete an annual report- the first report will cover FY 7-1-2017 thru 6-30-2018. The Sr. Vice President and CEO will ensure that annual reports are completed on or before September 30th of each year. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual audit. The 2016 annual audit was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence from Bankruptcy NPHS will complete its annual audit and file a copy with DDAP. The CEO/Sr. Vice President will ensure that the audit is done on an annual basis. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on the review of eight client records on February 6-7, 2018, the facility failed to obtain valid consent to release forms in records, #1, 2 and 4.
Client #1 - A release documented for a doctor did not specify what information was to be release. Additionly, there were three other release forms that were signed by the client, but not dated.
Client #2 - Based on a review of several progress notes, the facility gave identifying information on the client to a family member without a consent on file for that family member.
Client #4 - A release for a funding source was signed and dated November 23, 2017, the 23rd was crossed out and changed to the 28th, with indicating who made the change. The release was also signed by staff on November 22, 2017 and not the 23rd. Additionally, there was another release for another funding source signed and dated for November 22, 2017 by the client, but was not signed by staff until November 23, 2017.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The training coordinator will provide two trainings focusing on the appropriate way to complete a consent to release form. This training will also include identifying specific contacts that require a consent to release information, as well as what information that may be released to various agencies and individuals. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on review of eight client records on February 6-7, 2018, the facility failed to have documented verbiage "clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records" in all client records reviewed.
These findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The clinical director will update the client's bills of rights to include verbiage ""clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records". |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on review of eight client records on February 6-7, 2018, the facility failed to provide physical examinations during intake in client records, #3 and 7.
Client #3 was admitted on 12/12/17 and did not receive their physcial until 12/22/17.
Client #7 was admitted on 10/2/17 and did not receive their physcial until 10/11/17.
These findings were discussed with facilty staff during the licensing inspection.
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Plan of Correction
The clinical supervisor and the unit assigned nurse will assure that all clients are scheduled to have a physical examination within 7 days of their admission. The nurse will document all scheduled history and physical appointment on a monthly calendar that will be reviewed by the clinical supervisor daily. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of eight client records on February 6-7, 2018, the facility failed to provide evaluative evaluations for clients, #2, 4, 5, 7 and 8. The facility only documented what the client stated.
These findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will conduct an assessment and identify all clinicians who struggle with writing an evaluative evaluation. Once these individuals are identified they will attend assessment and clinical formulation training provided by CBH network development department. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on review of three discharged client records on February 6-7, 2018, the facility failed to provide documentation of a follow-up for all three clients.
Client #6 was admitted on 11/23/16 and was discharged on 1/12/17.
Client #7 was admitted on 10/2/17 and was discharged on 11/30/17.
Client #8 was admitted on 3/31/17 and was discharged on 4/19/17.
These findings were reviewed with the facility during the licening inspection.
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Plan of Correction
The clinical supervisor will conduct a monthly audit of 25% of the clients who have been discharged to assure that the all follow procedures including documentation of a follow-up are completed. |