INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2018 through February 9, 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 IOP-CAP was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual report. The 2016 annual report was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence for Bankruptcy NPHS will complete an annual report- the first report will cover FY 7-1-2017 thru 6-30-2018. The Sr. Vice President and CEO will ensure that annual reports are completed on or before September 30th of each year. |
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 a review administration paperwork on February 9, 2018, the project failed to provide a copy of their annual audit. The 2016 annual audit was requested.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon emergence from Bankruptcy NPHS will complete its annual audit and file a copy with DDAP. The CEO/Sr. Vice President will ensure that the audit is done on an annual basis. |
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 client records on February 8-9, 2018, the facility failed to document an informed and voluntary consent in client records, #1, 3, 4 and 7.
Client #1 was admitted on November 21, 2017. The facility failed to have any consent to release forms on file for client #1.
Client #3 was admitted on December 1, 2017. A consent to release dated 12/1/17 for the client ' s emergency contact did not have the name of the emergency contact.
Client #4 was admitted on September 26, 2017. A consent to release dated 9/26/17 for the client ' s emergency contact did not have the name of the emergency contact.
Client #7 was admitted on May 19, 2017. A consent to release dated 5/19/17, for the client PO exceeded 4 PA Code 255.5 by allowing for the release of the client ' s psychiatric evaluation, psychosocial history and copies of the client ' s progress notes. Additionally, the expiration date was not document on the form and the witness signature/date was missing on the form.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 3-2-18, the Clinical Supervisor will train the IOP/CAP staff on how to document informed and voluntary consent in client's record. The training will also, including the type of information that it is allowed to disclose for legal entities like; court, and probation officers.
By 3-2-18, the clinical supervisor will review every active chart's informed consent to ensured regulations compliance. New releases that meet the requirements will be generated for the charts that are found out of compliance.
Beginning 2-28-18, any new released will be reviewed by the Clinical Supervisor and or the Secretary to ensured regulations compliance.
Beginning 2-28-18, clinical supervisor and or the secretary will review the electronic record to ensure that the different consents have been properly scanned into the electronic record.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records on February 7 and 8, 2018, the facility failed to document that the client was informed of their client rights in records, #1, 3 and 4.
Client #1 was admitted on November 21, 2017.
Client #3 was admitted on December 1, 2017.
Client #4 was admitted on September 26, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 3-5-18, the clinical supervisor will review every active chart to ensure that the participants have received a Client's Bill of Rights. A copy of the Bill of Rights will be reviewed, signed, given to the participant, and a copy scanned into the Electronic Record.
Beginning 2-28-18, any new client admitted into the IOP/CAP program will given the Client Bill of Rights to be reviewed, signed, and a copy will be scanned into the electronic record.
Beginning 2-28-18, clinical supervisor will review the electronic record to ensure that a copy of the Client Bill of Rights have been properly scanned into the electronic record
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of seven client records on February 7 and 8, 2018, the facility failed to document that the client oriented to the facility in records, #1, 3 and 4.
Client #1 was admitted on November 21, 2017.
Client #3 was admitted on December 1, 2017.
Client #4 was admitted on September 26, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 3-5-18, the clinical supervisor will review every active chart to ensure that the orientation verification has been scanned into the electronic record. For those charts the a verification is not found, the client will be have an orientation, and the orientation verification will be scanned into the electronic record.
Beginning 2-28-18, any new admission into the IOP/CAP program will given an orientation by Community Recovery Specialist, and a verification of attendance will be scanned into the electronic record.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven client records on February 7 and 8, 2018, the facility failed to document that the client sign a consent to treatment in record, #1.
Client #1 was admitted on November 21, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 3-5-18, the clinical supervisor will review every active chart to ensure that the each client has signed and received a Consent to Treatment.
By 3-5-18, Clinical supervisor will train staff on the proper documentation needed in the admission process, including the Consent to Treatment.
Beginning 3-5-18, any new admission into the IOP/CAP program will be given a Consent to Treatment to review, sign, and then scan into the electronic record.
Beginning 3-5-18, clinical supervisor will review the electronic record to ensure that a copy of the Consent to Treatment have been properly scanned into the electronic record.
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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 a review of seven client records on February 8-9, 2018, the facility failed to document within the required time comprehensive treatment plan in client records, #2, 4 and 6.
Client #2 was admitted on August 4, 2017. The preliminary treatment plan was completed on 8/4/17 and the comprehensive treatment plan was not completed until October 4, 2017. Two months after the clients admit date.
Client #4 was admitted on September 26, 2017. The preliminary treatment plan was completed on 9/26/17 and as of the date of the licensing inspection the comprehensive treatment plan was not documented.
Client #6 was admitted July 17, 2017 and discharged on October 17, 2017. The preliminary treatment plan was completed on 7/17/17 and the comprehensive treatment plan was not completed until 8/24/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2-23-18, the IOP/CAP counselors were trained by the Clinical Supervisor on due dates for treatment plans. Counselors were reminded that a comprehensive treatment plan needs to be developed within the first 30 days from admission.
Beginning 3-5-18, the clinical supervisor will conduct weekly chart reviews to ensure that the counselor adhere to the treatment plan regulations.
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709.93(a) 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:
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Observations
Based on a review of seven client records on February 8-9, 2018, the facility failed to document who all were involved in the client's case consultation in records, #1, 2, 4, 5 and 6.
Client #1's case consultations took place on 1/5/18 and 2/7/18.
Client #2's case consultations took place on 11/1/17 and 1/19/18.
Client #4's case consultation took place on 12/8/17.
Client #5's case consultation took place on 10/27/17.
Client #6's case consultation took place on 9/29/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2-23-18, the IOP/CAP staff was instructed to type the names and credentials of every person that participates in a client's case conference.
Beginning 3-5-18, the Clinical Supervisor will conduct weekly reviews to ensure that the names and credentials of the people that participated in the Case Conferences are typed in the notes.
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