INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health Systems, IOP-CAP 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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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
The physical plant inspection was conducted on August 16, 2016 and August 17, 2016. The facility's trash compactor outside of the kitchen was filled to the point that it was unable to to be closed, thus unable to to prevent the penetration of insects and rodents.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Housekeeping is responsible for insuring that the trash compacted is empty of a timely basis, in order to prevent access by pest and rodents. The trash compacted is scheduled to be emptied on a daily basis, she will monitor the removal of trash and insure that the compactor can be closed beginning immediately. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The physical plant tour took place on August 17, 2016. The storage room located on the first floor of the ADC building was used for the storage of discharged client records and the storage of gowns. The facility failed to ensure client's confidentiality by not having the records stored within a locked storage container.
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Plan of Correction
The room used to store discharges will be used exclusively for that purpose. Any other item located in the room besides discharges was removed on 9-27-16. The Clinical Supervisor will conduct monthly inspections of the room to ensure that it is only used to store discharges and that it is properly locked. |
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
Six client records were reviewed on August 18, 2016. The facility failed to obtain an informed and voluntary consent in three of six client records reviewed.
Client #1 - Consent to the Criminal Justice System did not specify the name of the agency that the disclosure is made to.
Client #3- Consent to the emergency contact was missing a dated signature of the client.
Client #4- Seven consents, one to the hospital, two to funding sources, an emergency contact, criminal justice system, probation and parole and a transportation program were missing the dated signatures of the client. Additionally, consent to the criminal justice system did not specify the name of the agency that the disclosure is made to.
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Plan of Correction
All consent forms will be reviewed and updated by the Sr. Vice President of Behavioral Health Services to ensure conformance with DDAP regulations with specific attention to Client signature and date; in service training will be provided during unit staff meetings and new forms will be issued to all staff on or before September 30, 2016. Full compliance will be obtained by October 1, 2016. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Six client records were reviewed on August 18, 2016. The facility failed to document that the client was offered a copy of a consent to the funding source in client record #3.
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Plan of Correction
All consent forms will be reviewed and updated by the Sr. Vice President of Behavioral Health Services to ensure conformance with DDAP regulations with specific attention to Client signature, date, and documentation of whether the client accepted or declined a copy of the consent; in service training will be provided during unit staff meetings and new forms will be issued to all staff on or before September 30, 2016. Full compliance will be obtained by October 1, 2016. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Six client records were reviewed for client rights on August 18, 2016. The facility failed to include on the facility's Patient Rights and Responsibility form the following verbiage: age, ethnicity, marital status and handicap.
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Plan of Correction
The Sr. Vice President will review all Participant handbooks for content related to client rights. The Sr. Vice President will also review the client rights provided in the Behavioral Access Center to ensure that the forms contain appropriate Participant signatures. The clinical supervisor on the program and the BAC will monitor the process to ensure that Participants are signing that they have been notified of their rights. Full compliance will be achieved by October 15, 2016
By 10-24-16, the counselors will give a copy of the Client Rights, that includes the necessary verbiage, to every active client. A signed copy of the document will be placed in the client's chart. Clinical supervisor will review active clients' files to ensure that the Client Rights are in the charts. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Six client records were reviewed on August 18, 2016 for treatment and rehabilitation services. The facility failed to document treatment and rehabilitation services in all six client records reviewed.
Client #1- the individual treatment and rehabilitation plan did not include written documentation of frequency of treatment and rehabilitation services.
Client #2- the individual treatment and rehabilitation plan did not include written documentation of frequency of treatment and rehabilitation services and proposed support services.
Client #3 was admitted to treatment on January 13, 2016 and is still an active client. There was no documentation of an individual treatment and rehabilitation plan as of the date of the licensing inspection.
Clients #4, #5, #6-the individual treatment and rehabilitation plan did not include written documentation of type and frequency of treatment and rehabilitation services and proposed support services.
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Plan of Correction
By 9-30-16, Clinical Supervisor will train staff on how to add a list of proposed support services when updating treatment plans.
By 9-30-16, Clinical Supervisor will train staff on how to include in the treatment plans the frequency of treatment and rehabilitation services.
Beginning 10-01-16, the Clinical supervisor will inspect participants' electronic charts to ensure:
1. that treatment plans are completed on time and are located in the right electronic file.
2. that treatment plans include propose support services list
3. that treatment plans include frequency of treatment and rehabilitation services.
By 10-31-16, the counselors will meet with every active client to ensure that every treatment plan has a list of proposed support services, a list of treatment and rehabilitation services and their frequencies, and to ensure that every treatment plan has been completed.
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709.93(a) LICENSURE Client records
709.93. 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:
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Observations
Six client records were reviewed on August 18, 2016. Two of the six client records did not contain documentation of any follow-up information.
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Plan of Correction
Beginning 10-01-16, the Clinical supervisor will send a follow up letter to participants that have completed treatment in IOP/CAP. A copy of the letter will be scanned into the electronic record as verification that the letter was sent. |