INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System DD/FIR 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the facilty personnel records, the facility failed to ensure that a counselor assistant with a Bachelors Degree received close supervision for at least the first 6 months of employment.
Employee # 7, who has attained a bachelors degree, was promoted to the counselor assistant position on 10/20/17. This employee received close supervision for only four months. Documentation of this supervision period began on 10/20/17 and ended 2/2/18.
The findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
director of residential services with meet with the clinical supervisor to review the supervision requirements of a counselor assistant.
responsible party: Clinical Director
completion date: 11/1/2018
the clinical supervisor will provide monthly supervision to the clinical director monthly. the clinical director will create a log sheet to ensure that this does not occur again. beginning 11/16/2018 |
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 and the facility's Staffing Requirement Facility Summary Report, the facility failed to complete an annual individual training plan for the 2018 training year in four personnel records, #15, 16, 17 and 18. Additionally, employee #10 had a training year plan, but it was not signed or dated by the employee.
Employee #10 was hired 1/13/14.
Employee #15 was hired 09/07/10.
Employee #16 was hired 05/09/94.
Employee #17 was hired 07/22/13.
Employee #18 was hired 02/12/18.
The findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
POC
The clinical supervisor will create a check sheet identifying all staff and monitor that Training plans are completed within 30 days of hire for new employees and by January 31, of each year for all other employees Responsible?Clinical Supervisor - Date of completion ---11-1-18
the clinical supervisor will complete an annual training plan for employee #15,16,17, and 18 by 11/16/2018
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704.12(a)(1)(i) LICENSURE Client/couns ratios
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.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the facility's Staffing Requirement Summary Report, the facility failed to provide one FTE primary care staff person for every seven clients during primary care hours.
On 8/26/18 the census at the facility was 19 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m.-7:00 a.m., there were two staff available during these hours.
8:00am-9:00 a.m., there were two staff available during these hours.
6:00pm-7:00pm, there were two staff available during these hours.
8:00pm-11:00pm ,there were two staff available during these hours.
On 8/28/18 the census at the facility was 19 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m.-7:00 a.m., there were two staff available during these hours.
8:00am-9:00 a.m., there were two staff available during these hours.
6:00pm-7:00pm, there were two staff available during these hours.
8:00pm-11:00pm, there were two staff available during these hours.
On 8/29/18 the census at the facility was 19 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m.-7:00 a.m.,there were two staff available during these hours.
8:00am-9:00 a.m., there were two staff available during these hours.
6:00pm-7:00pm , there were two staff available during these hours.
8:00pm-11:00pm, there were two staff available during these hours.
On 8/30/18 the census at the facility was 15 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m.-7:00 a.m., there were two staff available during these hours.
8:00am-9:00 a.m., there were two staff available during these hours.
6:00pm-7:00pm, there were two staff available during these hours.
8:00pm-11:00pm, there were two staff available during these hours.
On 9/01/18 the census at the facility was 17 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00 a.m.-7:00 a.m., there were two staff available during these hours.
8:00am-9:00 a.m., there were two staff available during these hours.
5:00pm-7:00pm, there were two staff available during these hours.
8:00pm-12:00pm, there were two staff available during these hours.
The findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will request an exception to include- Addiction Recovery Assistants and House Nursing supervisors in the "primary care" number which will resolve the staff to client ratio during "sleeping" hours for patients. Request will be submitted to DDAP on or before 10/31/18 |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate toilet and wash rooms. The exhaust fan in the South wing rest room was not functioning.
The finding was discuss during the licensing inspection.
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Plan of Correction
The NPHS Maintenance Department will repair all exhaust motors in the bathrooms and repair the windows so that they are operational. Maintenance Department will monitor on a monthly basis during environmental rounds.
Responsible Party: Director of Facilities Management Completion Date: 11-30-18
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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
Based on the review of administrative documented on September 4 through the 5, 2-18, the facility failed to obtain an annual financial audit for audit year 2017.
This is a repeat citation.
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Plan of Correction
The CEO will request an exception to 709.25 based on NPHS recent Bankruptcy. Compliance with the financial audit requirement cannot be met until December 2019
the exception was submitted and approved on 11/9/2018 |
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 twenty client records, the facility failed to document a valid consent to release information. The facility consent template states that the consent may only be revoked by notifying the facility Medical Records Department.
Client #1 was admitted on 8/28/18 and was an active client at the time of the licensing inspection.
Client #2 was admitted on 8/29/18 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 8/18/18 and was an active client at the time of the licensing inspection.
Client #5 was admitted on 5/24/18 and was discharged on 07/16/18.
Client #6 was admitted on 6/10/18 and was discharged on 7/12/18.
Client #7 was admitted on 6/14/18 and was discharged on 7/14/18.
Client #8 was admitted on 9/10/18 and was an active client at the time of the licensing visit.
Client #9 was admitted on 9/07/18 and was an active client at the time of the licensing visit.
Client #10 was admitted on 9/11/18 and was an active client at the time of the licensing visit.
Client #11 was admitted on 9/08/18 and was an active client at the time of the licensing visit.
Client #12 was admitted on 8/21/18 and was discharged on 8/28/18.
Client #13 was admitted on 8/13/18 and was discharged on 8/18/18.
Client #14 was admitted on 5/22/18 and was discharged on 5/24/18.
Client #15 was admitted on 10/03/18 and was an active client at the time of the licensing visit.
Client #16 was admitted on 10/04/18 and was an active client at the time of the licensing visit.
Client #17 was admitted on 10/01/18 and was an active client at the time of the licensing visit.
Client #18 was admitted on 4/29/18 and was discharged on 5/02/18.
Client #19 was admitted on 5/01/18 and was discharged on 5/08/18.
Client #20 was admitted on 6/03/18 and discharged on 6/08/18.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The Sr. Vice President of Behavioral Services will review and update all consents to release information removing references to the Medical Records Department and indicating that consent can be withdrawn by giving verbal or written consent to any clinical staff member
Responsible Person; SrVP Completion Date 10/31/18
the clinical director will have corrected consent forms presented and explain to all active clients
responsible person- clinical director
completion date 11-16-18
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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
Based on a review of twenty client records, facility failed to document the purpose of the disclosure on the following consent to release forms.
Client #1 - consent to release to an govenment agency dated 8/26/18.
Client #7 - consent to release to an govenment agency dated 6/14/18.
Client #10 - consent to release to an govenment agency dated 9/11/18.
Client #17 - consent to release to an govenment agency dated 10/01/18.
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
The Clinical Supervisor will provide in-service training to all staff regarding the proper completion of consents, training will include all aspects of the consent .
Responsible Party: Clinical Supervisor Completion Date 1/15/19
Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that staff members are correctly completing all consents
Responsible Person- Clinical supervisor Completion Date 2/15/19
the clinical director will have corrected consent forms presented and explain to all active clients
responsible person- clinical director
completion date 11-16-18
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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
Based on a review of twenty client records, the facility failed to document that the client was offered a copy of their consent to release form in client records: #1, 7, 10, 15,16 and 17.
Client #1 - consent to release form for the funding agency dated 8/26/18.
Client #7 - consent to release form for the funding agency dated 6/14/18.
Client #10 - two consent to release forms for funding agencies dated 9/11/18.
Client #15 - two consent to release forms for funding agencies dated 10/03/18.
Client #16 - two consent to release forms for funding agencies dated 10/04/18.
Client #17 - consent to release form for the funding agency dated 10/01/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will provide in-service training to all staff regarding the proper completion of consents, training will include all aspects of the consent including the requirement to offer a copy of the form and document the offer.
Responsible Party: Clinical Supervisor Completion Date 1/15/19
Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that staff members are correctly completing all consents
Responsible Person- Clinical supervisor Completion Date 2/15/19
the clinical director will have corrected consent forms presented and explain to all active clients
responsible person- clinical director
completion date 11-16-18
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709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
A review of twenty client records revealed that the facility failed to document that clients had been informed of their rights. The client rights did not address the client's ability to review and amend their clinical record.
Client #2 admitted 8/29/18 and still active at the time of the inspection.
Client #4 admitted 8/13/18 and still active at the time of the inspection.
Client #5 admitted 5/22/18 and discharged 7/16/18.
Client #6 admitted 6/08/18 and discharged 7/12/18.
Clients #7 admitted 6/14/18 and discharged 7/14/18.
Clients #9 admitted 9/07/18 and still active at the time of the inspection.
Clients #10 admitted 9/11/18 and still active at the time of the inspection.
Clients #11 admitted 9/08/18 and still active at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
POC
The Clinical Supervisors will provide and in-service training to all staff on client rights and the responsibility to document that clients have been given and explained a copy of their rights.
Responsible Party: Clinical Supervisor Completion Date 1/15/19
Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that clients had been informed of their rights
Responsible Person- Clinical supervisor Completion Date 2/15/19
the clinical director will review the clients bill of rights to those active clients who where not informed of there rights review it with them, followed by having the client sign and date the bill of rights. a signed copy will be placed in the clients charts
responsible person- clinical director
completion date 11-16-18
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of six methadone client records, the facility facility to obtain a written consent before administering methadone.
Client records #15, #16, #17, #19 and #20 did not contain documentation of written consent to treat these clients with methadone.
Client #15 was admitted on 10/03/18 and was still active at the time of the inspection. This clients initial dose was on 10/03/18.
Client #16 was admitted on 10/04/18 and was still active at the time of the inspection. This clients initial dose was on 10/04/18.
Client #17 was admitted on 10/01/18 and was still active at the time of the inspection. This clients initial dose was on 10/02/18.
Client #19 admitted 5/01/18 and discharged 5/08/18. This clients initial dose was on 05/02/18
Client #20 admitted 6/03/18 and discharged 6/08/18. This clients initial dose was on 06/04/18
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
The Clinical Supervisor will provide in-service training to all staff regarding the proper completion of consents, training will include all aspects of the consent including the requirement to offer a copy of the form and document the offer.
Responsible Party: Clinical Supervisor Completion Date 1/15/19
Clinical Supervisors will conduct Random monitor of three (3) charts per clinician per month to validate that clients have signed an consent to receiving methadone
Responsible Person- Clinical supervisor Completion Date 2/15/19
the clinical director will review the the consents for the use of methadone to those active clients who did not give consent to the use of methadone and have them sign and date the consent. a signed copy will be placed in the clients charts
responsible person- clinical director
completion date 11-16-18
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