INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 2, an abbreviated on-site inspection, conducted on May 3, 2021 through May 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-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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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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in four of seven client records reviewed.
Client # 3 was admitted on February 14, 2020 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client and witness on February 14, 2020 and it expired on February 14, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after February 14, 2021.
Client # 5 was admitted on May 19, 2017 and was discharged on September 18, 2020. A release of information form to the funding source was signed by the client and witness on May 18, 2018 and it expired on May 18, 2019. A new release of information form was signed by the client and witness on August 10, 2020. There was evidence of disclosures to the funding source between May 18, 2019 when the first release form expired and August 10, 2020 when the new release form was signed.
Client # 6 was admitted on February 22, 2019 and was discharged on December 24, 2020. The release of information form to the funding source was signed by the client and witness on February 22, 2019 and it expired on February 22, 2020. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after February 22, 2020.
Client # 7 was admitted on December 20, 2019 and was discharged on March 10, 2021. The release of information form to the funding source was signed by the client and witness on December 20, 2019 and it expired on December 20, 2020. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after December 20, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Goldman Clinic Staff will review all charts and update all consent forms to ensure compliance. Counselors will be responsible to conduct annual checks to maintain compliance. Clinical Supervisors will conduct random audit quarterly to ensure compliance. |
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 the facility's October 2019 through April 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility. Incidents that occurred on the following dates were not reported to the Department at all:
January 17, 2020
June 23, 2020
July 24, 2020
August 4, 2020
August 24, 2020
October 29, 2020
December 24, 2020
March 19, 2021
April 8, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Staff members will complete incident reports as required. Incident reports will be submitted to the Executive Director for review. Once reviewed by the Executive Director, the Office Manager will be responsible to submit unusual incident reports to DDAP within the allotted time frame of three business days. With respect to the incident reports that were identified as a violation, those reports will be sent to DDAP no later than May 25, 2021. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in four of five applicable patient records reviewed.
Patient # 1 was admitted on February 11, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that for the month of April 2021, there was only 30 minutes of psychotherapy provided to the patient.
Patient # 3 was admitted on February 14, 2020 and was still active at the time of the inspection. The record of service and progress notes documented that for the months of February 2021, March 2021, and April 2021, there was zero minutes of psychotherapy provided to the patient. Additionally, for the month of January 2021, there was only 2 hours of psychotherapy provided to the patient.
Patient # 4 was admitted on October 14, 2020 and was still active at the time of the inspection. The record of service and progress notes documented that for the month of April 2021, there was only 1 hour and 45 minutes of psychotherapy provided to the patient. Additionally, for the month of January 2021, there was only 1 hour and 30 minutes of psychotherapy provided to the patient.
Patient # 7 was admitted on December 20, 2019 and was discharged on March 10, 2021. The record of service and progress notes documented that for the month of January 2021 there was only 1 hour and 25 minutes of psychotherapy provided to the patient. Additionally, for the month of February 2021, there was only hour and 55 minutes of psychotherapy provided to the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Clinic Counselors will ensure they are providing 2.5 hours of psychotherapy monthly during the first tow years of treatment. Goldman Clinic Counselors will be required to track their caseloads and compliance on their encounter sheets. Counselors will use the hold system in Avatar to enforce compliance. Counselors will be responsible for documented outreach fore participants who miss counseling sessions. Caseloads will be monitored and reviewed monthly by Goldman Management. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the facility failed to document a complete personal history in one of five applicable patient records reviewed.
Patient # 3 was admitted on February 14, 2020 and was still active at the time of the inspection. There was no completed personal history documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman staff will complete personal history upon admission as required. The patient is in a nursing home. The counselor will contact the nursing home and arrange for a telemedicine session to complete personal history no later than June 1, 2021. Clinical supervisors will monitor charts for nursing home clients on a monthly basis to ensure all requirements are met. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation in one of five applicable patient records reviewed.
Patient # 3 was admitted on February 14, 2020 and was still active at the time of the inspection. There was no completed psychosocial evaluation documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Psycho-social evaluations will be completed within 48 hours business hours of admission by primary counselor. Clinical supervisors will conduct random chart audits to ensure compliance.
The patient is currently in a nursing home. The counselor will make arrangements to conduct the psychosocial via tele-medicine no later than June 1, 2021. |
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
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient ' s status was completed by the patient ' s counselor and was reviewed, dated and signed by the medical director in one of three applicable patient records reviewed.
Patient # 3 was admitted on February 14, 2020 and was still active at the time of the inspection. There was no annual evaluation of the patient ' s status completed by the counselor documented in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Counselors will be required to review caseloads monthly and complete annual evaluations. Clinical Supervisors will review charts quarterly to ensure compliance.
With respect to the deficiency, the patient is currently in a nursing home. The counselor will arrange to complete the annual evaluation via tele-medicine no later than June 1, 2021. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the facility failed to review, reevaluate, modify, and update each patient's treatment plan every 60 days in four of six applicable patient records reviewed.
Patient #2 was admitted on July 2, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on July 6, 2020 and the next update was due no later than September 6, 2020; however, the update was not completed until January 7, 2021.
Patient # 4 was admitted on October 14, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 5, 2021 and the next update was due no later than April 5, 2021; however, the update was not completed until April 23, 2021.
Patient # 6 was admitted on February 22, 2019 and was discharged on December 24, 2020. A treatment plan update was completed on March 25, 2020 and the next update was due no later than May 25, 2020; however, the update was not completed prior to discharge.
Patient # 7 was admitted on December 20, 2019 and was discharged on March 10, 2021. A treatment plan update was completed on June 5, 2020 and the next update was due no later than August 5, 2020; however, the update was not completed until September 25, 2020
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Goldman Counselors will be required to complete treatment plan updates at minimum every 60 days. Clinical Supervisors will be required to monitor compliance through quarterly chart audits. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and 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 a 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 patient.
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Observations
Based on a review of the facility's October 2019 through April 2021 unusual incident logs, the facility failed to notify the Department within 48 hours of the offsite death of an active patient in three incidents during the review period.
The facility was notified of the three separate incidents on the following dates, however, did not report it to the Department:
July 2, 2020
October 19, 2020
April 15, 2021
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Goldman Staff members will complete incident reports as required. Incident reports will be submitted to the Executive Director for review. Once reviewed by the Executive Director, the Office Manager will be responsible to submit unusual incident reports to DDAP within the allotted time frame of 48 hours.
With respect to the three deficiencies, reports will be sent to DDAP no later than May 25, 2021. |