INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-15, 2008 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. The following deficiencies were identified during this inspection and a plan of correction is due on September 23, 2008.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records on August 19, 2008, the facility failed to document a fire drill every month.
Findings:
The facility did not document a fire drill for July 2008.
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Plan of Correction
A mandatory in-service was held on Monday, August 25, 2008. All managers from the Tower building were required to attend. The Fire Marshall presented the education. A review was completed regarding the process for completing the fire drill documentation. A new process was put in place which requires all documentation to be submitted to the CEO's office within 24 hours of the fire drill. All documentation will be reviewed for content and completeness for the CEO. If the documentation is incomplete, the manager will be notified to correct the issues. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records on August 19, 2008, the facility failed to document alternate exit routes used during fire drills.
Findings:
The facility did not document alternate exit routes used from November 2007 through June 2008.
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Plan of Correction
Education will be provided on each unit of the Tower building regarding the use of the alternate fire tower. The Fire Marshall will review the process and actually go down the fire tower with each manager. By December of 2008, all units will be educated to the use of this exit and a fire drill will be conducted utilizing this exit. Appropriate documentation of the use of this exit will be completed and placed in the Fire Drill Manual. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of three client records on August 15, 2008, three were required to have an individual treatment and rehabilitation plan.
Findings:
The facility failed to document a complete treatment plan update in two of three client records reviewed, #1 and 2. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
Clinical Supervisor will conduct an in-service on treatment plan evaluations on 09-11-09. All the treatment plan updates will be done at least every 60 days and will include an assessment of the client's progress in relationship to the stated goals in accordance with 711.92(d). Clinical Supervisor will ensure that this process takes place by conducting chart review on a weekly basis. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of three client records on August 15, 2008, three of three client records were required to have an individual treatment and rehabilitation plan.
Findings:
The facility failed to document the proposed type of support service in two of three client records reviewed, #1 and 2.
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Plan of Correction
Clinical Supervisor will conduct an in-service on treatment plan on 09-11-08 and will cover the area of proposed type of support services. All the treatment plan updates will include a list of proposed type of support services in accordance with 711.92(c)(3). Clinical Supervisor will ensure that this process takes place by conducting chart review on a wkly basis. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of three client records on August 15, 2008, three were required to have treatment plan updates.
Findings:
The facility failed to document a complete treatment plan update in two of three client records, #1 and 2. Treatment plan updates did not include an assessment of the client's progress in relationship to all of the stated goals of the treatment plan.
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Plan of Correction
Clinical Supervisor will conduct an in-service on treatment plan evaluations on 09-25-08. All the IOP/CAP counselors will attend this training. Every treatment plan update will be done at least every 60 days and will include a review of progress of short and long-term goals that were stated in the prior treatment plan in accordance to 711.92(c)(1). Clinical Supervisor will ensure that this process takes place by conducting chart review on a weekly basis. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of three client records on August 15, 2008, the facility failed to obtain an informed and voluntary consent from the client in three of three client records where required.
Findings:
The Consent to Treatment Forms in client records # 1, 2 and 3 specified that the client's consent to release information was not required when the facility released information relative to homicidal or suicidal ideation. Additionally, the consent to release information forms signed by the clients did not allow for verbal revocation of the consent in client records #1, 2 and 3.
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Plan of Correction
Clinical Supervisor will update all the consent to release information forms to allow the clients to verbally revoke the consent. Clinical Supervisor will update The Consent to Treatment Forms to remove the section where it is stated that the client's consent to release infromation is not required when the facility releases information related to homicidal or suicidal ideation. These changes will take place by 09-15-08 and the Clinical Supervisor will monitor for compliance on a case by case basis. |