INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2010 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 September 24, 2010..
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Nineteen personnel records were reviewed on August 11, 2010 through August 16, 2010 and the staffing requirements facility summary report was reviewed on August 11, 2010 through August 12, 2010. There was no documentation of HIV/AIDS or TB/STD training in seven employee records. Of the seven, two was to have HIV/AIDS and TB/STD training within the first year of employment and the rest was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #3 was hired July 1, 2008 and was required to have HIV/AIDS & TB/STD training by July 1, 2009. There was no documentation of HIV/AIDS training in the employee's record as of August 16, 2010.
Employee #18 was hired August 8, 2008 and was required to have HIV/AIDS & TB/STD training by August 8, 2009. There was no documentation of HIV/AIDS training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #9 was hired August 11, 2008 and was required to have HIV/AIDS & TB/STD training by August 11, 2010. There was no documentation of HIV/AIDS& TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #10 was hired August 8, 2008 and was required to have HIV/AIDS & TB/STD training by August 8, 2010. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #11 was hired June 9, 2008 and was required to have HIV/AIDS & TB/STD training by June 9, 2010. There was no documentation of HIV/AIDS & TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
Employee #12 was hired June 9, 2008 and was required to have HIV/AIDS & TB/STD training by June 9, 2010. There was no documentation of TB/STD training documented in the staffing requirements facility summary report dated August 16, 2010.
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Plan of Correction
The New Employee orientation will be modified to include HIV/AIDS and First Aid training along with the TB/STD and CPR training in order to insure that all new hires obtain the DOH mandatory training requirements. The infection disease department will be responsible for providing HIV/AIDS and the education department will be responsible for providing First Aid. The modification will take place by November 2010.
By December 31, 2010 all current staff who is not compliant for training will receive the DOH mandatory training.
The Program Directors and the AVP or nursing will be responsible for ensuring that all staff has obtained required training.
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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 tour of the facility ' s physical plant and an interview with the facility director, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The facility was required to ventilate all toilets and wash rooms by exhaust fan or window.
The facility did not ventilate the men ' s toilets on the 4th floor of the Tower Building.
The facility did not ventilate the wash rooms in client bedrooms # 455, 463 and 464 of the ADC Building.
The facility director confirmed that ventilation was not provided in the identified toilets and wash rooms.
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Plan of Correction
All the vent motors were replaced during the survey. The Director of Plant Facilities will place the monitoring of vent motors as a part of the monthly preventative maintenance rounds.Fully compliance 08/26/2010. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a tour of the facility ' s physical plant and an interview with the facility director, the facility failed to maintain cold food at or below 40 findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The temperature of the refrigerator in the kitchen, on the 4th floor Tower Building was 50
The facility director confirmed that the refrigerator was 50
The facility did not document temperature logs, so it was impossible to determine how long the refrigerator temperature had exceeded 40
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Plan of Correction
The Clinical Supervisor will review the protocol and procedure with staff on proper refigerator temperature. The CRS will maintain a dialy log. Clinical Supervisor will review the log on a weekly basis. Maintanence will be call when refrigerator temperature changes. Fully compliance by September 1, 2010. |
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 the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
This program is located on the fourth floors of the Tower Building and the ACD Building.
The facility fire drill record for the Tower Building did not include any record of a fire drill for June 2010.
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The staff person questioned confirmed that there was no documentation of a June 2010 Fire drills, nor were there any observation sheets completed for December 31, 2009.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
This program is located on the fourth floors of the Tower Building and the ACD Building DD/FIR program is on a locked unit and total evacuation is only completed if there is an actual fire; otherwise, the facility defends from within by evacuating horizontally to one side or another of a one hour rated smoke barrier or two hour fire wall.
None of the fire drills for this program identified an exit route used or the transfer to one side of the smoke barrier or horizontal exit.
The Tower Building fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The Tower Building fire drill record of February 25, 2010 only contained documentation for the ninth floor of the Tower building.
The Tower Building fire drill conducted on April 6, 2010 did not include the number of participants.
The Tower Building fire drill conducted on May 26, 2010 had a note that the indicated no evacuation due to early morning.
The staff person questioned confirmed the findings.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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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 completely document psychosocial evaluations in six of seven client records reviewed.
The finding includes:
Seven records were reviewed on August 19, 2010. Psychosocial evaluations were required in seven records reviewed.
Client records #1 failed to document the client ' s problem/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the client's attitude toward treatment.
Client records #2 and 3 failed to document the client's problem/needs, assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client records #4 failed to document the client's assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client records #5 failed to document the client's problem/needs, assets/strengths, coping mechanisms and negative factors that might inhibit treatment.
Client records #7 failed to document the client's support systems, coping mechanisms, negative factors that might inhibit treatment and the client's attitude toward treatment.
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Plan of Correction
The Director of Outpatient Psychiatry will develop a three hour training sessions on completing psychosocial evaluations and will provide the training to all clinical staff by November 30, 2010.
A psychologist from the Outpatient Department will conduct random reviews of evaluations and meet with clinical staff to review case formulations/evaluations for the next 90 days.
The clinical supervisors will review three cases per month of each clinician for the next 90 days, focusing on psychosocial evaluations.
Ongoing monitoring will be conducted by the clinical supervisors and full compliance will occur by December 31, 2010.
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