INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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. The following deficiencies were identified during this inspection.
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Plan of Correction
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct an unannounced fire drill for the months of October 2018 through January 2019 and August 2019. Additionally, the facility failed to identify, on their fire drill log, the amount of time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill for every fire drill conducted from February 2019 to August 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Log was updated on 9/12/19 to include the amount of time it takes for evacuation, the exit route used and the number of persons in the facility at the time of the drill.
The new log will be fully implemented by 10/30/19.
The IS3 facility director is responsible for completing the log and the NPHS safety office is responsible for reviewing on a monthly basis.
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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
The facility failed to develop, and make available to the public, their 2018 annual report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No annual report for FY 2018 was completed because of the prior bankruptcy status of the institution.
The Sr. Vice President will complete and annual report for fiscal year ending June 30, 2019 by November 30, 2019.
Annual Report will be posted on the website by December 15, 2019
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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
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No audit was completed for FY2018 because of the prior bankruptcy status of the organization.
The CFO is responsible for obtaining an audit for FY2019 and has engage a company to complete the audit.
Anticipated date of audit completion: December 30, 2019
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709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent form in one of seven client records.
Client # 7 was admitted on June 10, 2019 and was discharged on August 7, 2019. There was a consent to release information form signed and dated by the client on July 7, 2019; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure would be made to.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to include the specific information that was to be disclosed on a consent to release information form in two of seven client records.
Client # 3 was admitted on July 11, 2019 and was active at the time of the inspection. There was a consent to release information form to another provider signed and dated by the client on August 1, 2019; however, the consent form listed one of the items to be disclosed as "other" with no specification of what information would be released.
Client # 7 was admitted on June 10, 2019 and discharged on August 7, 2019. There was a consent to release information form signed and dated by the client on July 3, 2019; however, the consent form did not include the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on the consent form in two of seven client records.
Client # 1 was admitted on August 2, 2019 and was active at the time of the inspection. There was a consent to release information form to a government agency signed and dated by the client on August 2, 2019; however, the consent form did not include the purpose for disclosure.
Client # 4 was admitted on December 4, 2018 and was discharged on March 1, 2019. There was a consent to release information form to an individual signed and dated by the client on January 15, 2019; however, the consent form did not include the purpose for disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated signature of a witness on a consent to release information form in one of seven records.
Client # 5 was admitted on December 30, 2018 and was discharged on March 20, 2019. There were two consent to release information forms to other treatment providers signed and dated by the client on March 20, 2019; however, both consent forms did not include the dated witness signatures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to document the date, event or condition which the consent will expire on a consent form in two of seven client records.
Client # 5 was admitted on December 30, 2018 and was discharged on March 20, 2019. There were two consent to release information forms to other treatment providers signed and dated by the client on March 20, 2019; however, both consent forms did not have a date, event or condition upon which each consent would expire.
Client # 7 was admitted on June 10, 2019 and discharged on August 7, 2019. There was a consent to release information form signed and dated by the client on July 3, 2019; however, the consent form did not have a date, event or condition upon which the consent would expire.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide documentation verifying that each client record reviewed had given written acknowledgement that they were informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation that the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental if presented to the client.
All active Participants will be provided the new form to sign-copies will be placed in their records and they will be offered a copy of the form.
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
The clinical Supervisors of the program will be responsible for insuring that all currently active participants are provided with and sign the updated form.
Completion will be by 10/30/19
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to provide documentation that a client was notified, in writing, of the reason for the facility's decision to involuntarily terminate the client from treatment in one of four applicable client records reviewed.
Client # 7 was admitted on June 10, 2019 and was administratively discharged on August 7, 2019.
The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Residential Services will review the Administrative Discharge policy with all of the clinical supervisors by 10/15/19.
Clinical Supervisors will review the policy with counseling and nursing staff by 10/30/19.
The clinical supervisors will log all administrative discharges for next 3 months to ensure that notification of intent is given to Participants.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to properly document the frequency of services the client was to receive on the client's individual treatment plan in three of seven client records reviewed.
Client # 1 was admitted on August 2, 2019 and was active at the time of inspection. The comprehensive treatment plan was dated August 9, 2019.
Client # 2 was admitted on July 11, 2019 and active at the time of the inspection. The comprehensive treatment plan was dated July 18, 2019.
Client # 3 was admitted on July 11, 2019 and was active at the time of the inspection. The comprehensive treatment plan was dated July 18, 2019.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Clinical Supervisor will provide in-service training on the completion of treatment plans including the timeliness, frequency of services and all other elements as well as the requirement for client signatures and documentation of the clinical session during which the treatment plan was completed by October 15, 2019.
The Counselor will be responsible for insuring that client signature and clinical documentation have been completed-Ongoing
The Clinical Supervisor will conduct a focus review of all treatment plans for the next 60 days to insure that signatures and documentation are completed and will review this issue on an ongoing basis during staff supervision.
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