INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 6, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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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 provide documentation that the individual training plans were developed with input from both the employee and the supervisor in three of twelve applicable personnel records reviewed.
Employee # 1 was hired as the project director on January 1, 2008. The individual training plan was signed by the employee on January 29, 2020, but there was no documentation that it was developed with input from the supervisor.
Employee # 3 was hired as a clinical supervisor on March 1, 2017. The individual training plan was signed by the employee on January 31, 2020, but there was no documentation that it was developed with input from the supervisor.
Employee # 9 was hired as a counselor on July 10, 2017. The individual training plan was signed by the employee on July 31, 2020, but there was no documentation that it was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The annual training plan for the CEO was updated by the Sr. Vice President on August 13, 2020 to include the ongoing review/input and signature of the Chairman of the Board.
The 2020 Training plan of Employee #1 was sent to the Chairman on the Board for review/input and signature on August 13, 2020
The Sr. Vice President will monitor completion of plan on annual basis to ensure that citation does not recur.
The training plans for Employee # 3 & 9 were reviewed and signed by the clinical supervisor on August 10,2020,
The office coordinator will review all training plans before filing them to insure that they are signed by the clinical supervisors so that this deficiency does not recur. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on an administrative review, the facility failed to ensure that the full time equivalent (FTE) client/counselor ratio in outpatient programs did not exceed 35 active clients for 1 of 18 counselors employed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's standard workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #12's ratio calculation was as follows: 40/40 = 1(FTE); 36/1 = 36, which equals to a client/counselor ratio of 36:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reassigned the caseload of employee #12 to comply with regulations on August 7, 2020.
The office coordinator will monitor caseloads on a weekly basis to insure that they are maintained according to regulations. The coordinator will report to the supervisors and executive director any need to reassign caseloads. This Corrective action is ongoing.
The clinical supervisors will be responsible for maintaining appropriate case load assignments. This corrective action is ongoing. |
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 October 2019 through June 2020 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions during the months of February 2020 and May 2020. The fire drill logs during these months indicated that fire drills were conducted outside of the facility's posted operating hours.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Fire Marshall under the Direction of the VP of Operations will revised fire drill schedule to include additional drills over the course of the year with the hours of operation for the Outpatient SUD programs to insure that the number of required drills is completed.
The Fire Marshal will monitor and report to the VP of Operations on a quarterly basis to insure the citation does no recur |