INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 2009 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 and a plan of correction is due on October 26, 2009.
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Plan of Correction
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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 the review of personnel records, the facility failed to either document training plans or documented them late in five of eight personnel records reviewed.
The findings include:
Eight personnel records were reviewed on September 14, 2009. Training plans were required in seven personnel records. Per the facility's policy and procedure, training plans will be developed by January 31 of each year. Records #5, 6, 7 and 8 were documented late. Employee #5's training plan was completed on 2/3/09. Employee #6's training plan was completed on 2/9/09. Employee #7's training plan was completed on 2/2/09. Employee #8's training plan was completed on 2/3/09.
Also, record #3 was hired on 11/26/07; their individual training plan was not documented for training year 2009.
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Plan of Correction
The Residential Services department secretary will provide notice to the Progam Directors by the 24th of January of any education plan that has not been completed. The Director of Residential Services will monitor this process and ensure that all plans are back to the office by January 31. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure and document that counselors completed at least 25 hours of training for the training year 2008 in one of four personnel records.
Findings:
Eight personnel records were reviewed on September 14, 2009. Twenty-five hours of training per year were required in two personnel records. This was not documented in personnel record #6. Employee #6 had 17 hours of training for the training year 2008.
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Plan of Correction
Staff has been informed that all counselors require 25 hours of training per year regardless of FT/PT status. The Program Director and Clinical supervisor will monitor all training schedules to insure compliance with the regulations begining immediately and on an ongoing basis. Full compliance will be achieved by 12-31-09 |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a tour of the facility's physical plant, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
The findings include:
A tour of the facility's physical plant was conducted on September 23, 2009 at approximately 9:30 AM. The facility was required to provide slip-resistant surfaces in all bathtubs and showers. The facility did not provide slip-resistant surfaces in four of the four communal showers.
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Plan of Correction
The NPHS maintenace department has developed a schedule for applying slip resistent spray to all shower stalls. This schedule will be monitored by the head of Facilities Management and will begin immediatley and be ongoing according to the manufactures recommended schedule of application. The Program Director will monitor this effort during monthly facilites rounds.
Full compliance will be achieved by December 31, 2009 |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a tour of the facility's physical plant, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A tour of the facility's physical plant was conducted on September 23, 2009 at approximately 9:30 AM. A portable space heater was observed in a counselor's office during this inspection.
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Plan of Correction
A memo has been sent to all staff regarding regulations regarding the prohibition on the use of space heaters. The Program director will monitor this issue during monthly facilities rounds. The programs are currently compliant with this regulation. |
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 client records, the facility failed to document a psychosocial evaluation in four of five client records.
The findings include:
Five client records were reviewed on September 23, 2009. Psychosocial evaluations were required in five client records. The facility did not document a psychosocial evaluation in client records # 1, 3, 4 and 5.
The facility did not document a psychosocial evaluation to include the client's assets/strengths that can contribute to the resolution of identified problems in record # 1.
The facility did not document a psychosocial evaluation to include the client's potential or available support systems in records # 1, 3 and 5.
The facility did not document a psychosocial evaluation to include the client's preferred coping mechanisms in record # 3 and 5.
Client record # 4 did not document a legible psychosocial evaluation. There was documentation contained in the record that was not able to be read.
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Plan of Correction
The NPHS Education department will schedule a series of 3 hour trainings on the appropriate completion of psychosocial evaluations. The Program Directors and clinical supervisors will review at least 3 evaluations per staff per month during clinical supervison. Full compliance is expected by January 1, 2010 |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in three of four client records.
The findings include:
Five client records were reviewed on September 23, 2009. Of those five, treatment plan updates were required in four records. The facility did not document a treatment plan update to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records # 2, 3 and 4.
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Plan of Correction
The NPHS Education department will schedule a series of 3 hour inservice sessions on the appropriate completion of treatment plans and treatment plan updates. The Program Directors and Clinical supervisors will monitor improvement through the review of 3 charts per staff member per month during clinical supervison. Full compliance will occur by Jan 1, 2010. |