INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2010 through September 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Philadelphia Health Management Corporation/Chances 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 13, 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:
Twelve personnel records were reviewed on September 13, 2010 and the staffing requirements facility summary report was reviewed on September 13, 2010. There was no documentation of HIV/AIDS or TB/STD training in one employee records; Employee #12 was required to have HIV/AIDS or TB/STD within two years of their hire date.
Employee #12 was hired December 1, 2006 and was required to have HIV/AIDS & TB/STD training by December 1, 2008. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of September 13, 2010.
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Plan of Correction
Employee # 12 will attend the next HIV training scheduled at PHMC on 11/12/10 and will locate an approved TB/STD training to attend prior to 12/31/10. All new employees will be scheduled to attend required trainings within first year of hire at either PHMC or BHTEN. |
709.91(b)(6) LICENSURE Intake and admission
709.91. 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 psychosocial evaluations within 30 days of admission in seven of fifteen client records reviewed.
The finding includes:
Fifteen records were reviewed on September 14, 2010. Psychosocial evaluations were required in fifteen records reviewed. Based on the review of the facility's policy and procedure manual, psychosocial evaluations are required to be completed within 30 days of the client's admission date.
Client #1 was admitted on 5/19/10 and their psychosocial evaluations were to be completed by 6/19/10. Client #1's psychosocial evaluation was not completed until 7/26/10. Also, the clients assets/strengths, support systems and coping mechanisms were not evaluated in the documentation.
Client #2 was admitted on 7/20/10, but due to medical complications treatment was on hold until 8/9/10 when treatment was reinstated. Client's drug and alcohol, medical history and part of the clients personal history was completed on 7/20/10. The client's psychosocial evaluation was completed on 8/9/10 before the completion of the client's personal history.
Client #5 was admitted on 7/28/10 and their psychosocial evaluations was to be completed by 8/28/10; as of the date of the survey their was no of documentation of a psychosocial evaluation for client # 5.
Client #6 was admitted on 4/21/10 and their psychosocial evaluation was to be completed by 5/21/10. The psychosocial evaluation was not completed until 6/1/10. Also, the clients assets/strengths, support systems and coping mechanisms were not evaluated.
Client records #9 and 10 failed to document the client's assets/strengths, support systems and coping mechanisms.
Client record #13 was admitted on 4/13/10 and their psychosocial evaluations was to be completed by 5/13/10; as of the date of review there was no documentation of a psychosocial evaluation.
Client record #14 was admitted on 1/16/10 and their psychosocial evaluation was to be completed by 2/16/10; the psychosocial evaluation was not completed until 3/8/10.
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Plan of Correction
Management instructed staff that if the clients do not show for their individual sessions, they will need to pull them out of their group program in order to complete their biopsychosocials within the required 30 day intake period.
In addition, training sessions offered by the Philadelphia Department of Health (DBH) have been scheduled for 9/27, 10/4, 10/18, 10/25 and 11/1/10 and cover the following topics: Assessments, Treatment Plans, Progress Notes, Discharge Documentation and Compliance. Additional trainigs offered by the CHANCES Clinical Director and PHMC's Quality Management team will be offered quarterly thereafter.
PHMC's Quality Management team will also continue to perform quarterly chart audits and pay particular attention to completion dates of the biopsychosocial histories and treatment plans, and assessments of client assets/strengths, support systems and coping mechanisms. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to document comprehensive treatment plans within 30 days from admission in nine of fifteen records.
The findings include:
Fifteen records were reviewed on September 14, 2010. Comprehensive treatment plans were required in fifteen records reviewed. Per the facility's policy and procedure manual comprehensive treatment plans are to be completed within 30 days from the admission date. The completion of the client's history and psychosocial evaluations are also required to be completed within 30 days of admission.
Client #1 was admitted on 5/19/10 and their history and psychosocial evaluation was completed on 7/26/10. Their comprehensive treatment plan was completed on 6/17/10 before the completion of the client's personal history and psychosocial evaluation.
Client #2 was admitted on 7/20/10 but due to medical reason client treatment didn't start until 8/9/10. Client's history and psychosocial evaluation was completed on 8/20/10, the client's comprehensive treatment plan was not documented as of the date of the inspection.
Client #3 was admitted on 6/3/10 and their comprehensive treatment plan was to be completed by 7/20/10. The client's comprehensive treatment plan wasn't completed until 7/6/10.
Client #5 was admitted on 7/28/10 and their comprehensive treatment plan was to be completed by 8/28/10. The client's comprehensive treatment plan was completed on 8/28/10, but there was no documentation of a psychosocial evaluation.
Client #6 was admitted on 4/21/10 and their comprehensive treatment plan was to be completed by 5/21/10. The client's personal history and psychosocial evaluation was completed on 6/1/10 making them late per the facility's policy and procedure. This in return also made the client's comprehensive treatment plan, which was completed on 6/1/10, also late.
Client record #10 was admitted on 4/19/10 and their comprehensive treatment plan was to be completed by 5/19/10. The client's personal history, psychosocial evaluation and comprehensive treatment plan was completed on 5/19/10. The client did not sign or date that they worked on the treatment plan with the counselor.
Client record #11 was admitted on 5/10/10 and their comprehensive treatment plan was to be completed by 6/10/10. The client's personal history wasn't completed until 6/15/10 and their psychosocial evaluation completed 6/10/10. The client's comprehensive treatment plan wasn't completed until 6/18/10.
Client record #13 was admitted on 4/13/10 and their comprehensive treatment plan was to be completed by 5/13/10. The client's personal history wasn't completed by 5/13/10 and their psychosocial evaluation and comprehensive treatment plan wasn't documented in record reviewed.
Client record #14 was admitted on 1/16/10 and their comprehensive treatment plan was to be completed by 2/16/10. The client's personal history and psychosocial evaluation wasn't completed until 3/8/10. The client's comprehensive treatment plan was not completed until 3/8/10.
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Plan of Correction
Management instructed staff that if the clients do not show for their individual sessions, they will need to pull them out of their group program in order to complete their treatment plans within the required 30 day intake period.
In addition, training sessions offered by the Philadelphia Department of Health (DBH) have been scheduled for 9/27, 10/4, 10/18, 10/25 and 11/1/10 and cover the following topics: Assessments, Treatment Plans, Progress Notes, Discharge Documentation and Compliance. Additional trainigs offered by the CHANCES Clinical Director and PHMC's Quality Management team will be offered quarterly thereafter.
PHMC's Quality Management team will also continue to perform quarterly chart audits and pay particular attention to completion dates of the biopsychosocial histories and treatment plans, and assessments of client assets/strengths, support systems and coping mechanisms. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) 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 the review of client records, the facility failed to document support services in nine of fifteen records reviewed.
The findings include:
Fifteen client records were reviewed on September 14, 2010. Support services were required in fifteen client records. The facility did not document support services in client records #1, 2, 6, 8, 9, 11, 12, 13 and 14.
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Plan of Correction
Treatment Plans will be revised by 11/12/10 to include clearer prompts for clinicians to include support services.
In addition, training sessions offered by the Philadelphia Department of Health (DBH) have been scheduled for 9/27, 10/4, 10/18, 10/25 and 11/1/10 and cover the following topics: Assessments, Treatment Plans, Progress Notes, Discharge Documentation and Compliance. Additional trainigs offered by the CHANCES Clinical Director and PHMC's Quality Management team will be offered quarterly thereafter.
PHMC's Quality Management team will also continue to perform quarterly chart audits and pay particular attention to mention of client's support services in the treatment plans. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans that addressed the client's goals with time frames in four of seven discharge records reviewed.
The findings include:
Fifteen client records were reviewed on September 14, 2010. Aftercare plans were required in four of the seven discharge records reviewed, #11, 12, 13 and 15. Aftercare plan was not required in discharge record #9, 10, 14 due to client not successfully completing treatment. Client records #11, 12, 13 and 15 did not include documentation of the client's goals with time frames in the aftercare plans.
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Plan of Correction
Discharge plan will be revised by 11/12/10 to prompt clinicians to include specific goals and their timeframes for completion.
In addition, training sessions offered by the Philadelphia Department of Health (DBH) have been scheduled for 9/27, 10/4, 10/18, 10/25 and 11/1/10 and cover the following topics: Assessments, Treatment Plans, Progress Notes, Discharge Documentation and Compliance. Additional trainigs offered by the CHANCES Clinical Director and PHMC's Quality Management team will be offered quarterly thereafter.
PHMC's Quality Management team will also continue to perform quarterly chart audits and pay particular attention to aftercare plans and the mention of goals with specific timeframes. |