INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2008 through August 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 Return Program 1 & 2 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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705.10 (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
Based on a review of fire drill records, the facility failed to document unannounced fire drills at least once per month.
Finding:
There were no fire drill records for the month of July 2008.
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Plan of Correction
A mandatory educational in-service was conducted by the Fire Marshall on August 25, 2008 at 10am. All managers in the Tower building were required to attend. A reivew was completed regarding the process for completing the fire drill documentation. A new process was implemented which requires all documentation from the unit fire drill to be submitted to the CEO's office within 24 hours of the drill. All documentation will be reviewed for content and completeness by the CEO. If the documentation is non-compliant in any area, the manager will be called to correct the issues. This will begin immediately. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to document which exits routes were used during the fire drills for the past nine months.
Finding:
The fire drill logs did not document the exits used during the drills.
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Plan of Correction
The mandatory fire education inservice presented on August 25, 2008 by the Fire Marshall addressed the use of alternate exits during fire drills and the proper documentation of the exit utilized. Education will be provided by the Fire Marshall to all managers in the Tower building as to the use of the alternate fire tower during fire drills prior to the actual drill. By December 1, 2008, all managers will be educated as to the use of the alterante fire tower and a fire drill utilizing this route will be conducted. Appropriate documentation of the use of this exit and/or any other exit in the future will be completed and reviewed by the CEO before it is placed in the Fire Drill binder. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of four client records, the facility failed to document a comprehensive evaluation of the client in four of four client records where required.
Finding:
Client record #1 was missing the client's preferred coping mechanisms. Client record #2 was missing client assets/strengths that can contribute to the resolution of identified problems, potential or available client support systems, client's preferred coping mechanisms, and the counselor's conclusions regarding the client's attitude toward and ability to participate in the treatment process. Client record #3 was missing client assets/strengths that can contribute to the resolution of identified problems, the client's preferred coping mechanisms, and the counselor's conclusions regarding the client's attitude toward and ability to participate in the treatment process. Client record #4 was missing the client's preferred coping mechanisms.
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Plan of Correction
Additonal inservice training will be provided by the staff development department by October 31, 2008 on psychosocial evaluations. Staff will receive additional supervision focused on this area by the clinical supervisor and the program director over the next sixty days. The charts will be reviewed on a monthly basis by the clinical supervisor to ensure compliance and completion. |
711.52(e) ELEMENT Provision of services
711.52. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of four client records, the facility failed to document that counseling services were being provided to the client according to the individual treatment and rehabilitation plan for three of four clients.
Finding:
The facility failed to document weekly individual sessions as indicated on the individual treatment and rehabilitation plan in client records #1, 3, and 4.
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Plan of Correction
The clinical supervisor will monitor services provided to ensure that individual sessions and all other services are provided in accordance to the treatment plan. Increased monitoring of this issue will begin immediately and be ongoing. The clinical supervisor will monitor the charts in weekly team meetings and in monthly supervision session with the staff. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. 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 four client records, the facility failed to document on the consent to treatment form the need for a Court Order to release information without the client's consent for suicidal/homicidal ideation/intent in four of four records.
Finding:
The consent to treatment form in client records # 1, 2, 3, and 4 informed the client that information regarding suicidal/homicidal ideation could be released without their consent. Additionally, the consent to release information form signed by the client did not advise the client that verbal revocations had to be honored.
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Plan of Correction
The Confidential Information section of the consent for treatment will be revised. This will be under the direction of the Director of Residential Services, The VP for Behavioral Medicine and the Director of Patient/Client Access. This will be completed by 9/30/2008. The following changes will made to the form:
1. you have the right to verbally revoke consent to release information.
2. a court order is needed to divulge information without consent for clients expressing suicidal or homicidal ideation and/or intent. |