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 - 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 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 the fire drill records on August 21, 2008, the facility failed to document monthly fire drills.
Findings:
The facility failed to document a fire drill for the month of July 2008.
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Plan of Correction
A mandatory educational in-service was provided by the Fire Marshall for all Tower managers. This was held on Monday, August 25, 2008 at 10am. A review was completed on the proper process for completing the fire drill documentation. A new process was implemented by which the all the fire drill documentation will be submitted form the unit to the CEO's office within 24 hours of the drill. The documentation will be reviewed for content and completeness by the CEO. If the documentation is incomplete or requires a change in content, the CEO will contact the manager and the manager will correct the issues. This is effective 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 were used during the fire drills for the past nine months.
Findings:
The fire drill logs did not provide documentation of the exits used during the fire drills.
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Plan of Correction
The mandatory fire education provided by the Fire Marshall on 8/25/2008 for the Tower managers also included documentation of fire exit and use of alernate exits during fire drills. The Fire Marshall will provide education to each Tower manager on their unit. The Fire Marshall will review the process for utilizing the alternate fire tower during a fire drill. The Fire Marshall will do a physical walk through the fire route with the manager. This will be completed prior to the actual drill where the alternate fire tower will be utilized. By December 1, 2008, all education of managers in the tower will be completed along with a fire drill utilizing the alternate fire tower. Appropriate documentation of this drill and the use of this exit and/or any other exit utilized during any other drill will be reviewed by the CEO and placed in the Fire Drill Manual. |
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 on August 21, 2008, the facility failed to provide a comprehensive evaluation in three of four client records where required.
Findings:
Client record #1 was missing negative factors that might affect treatment, the client's attitude toward and ability to participate in the treatment process, and the counselor's conclusions/impressions of the client's attitude toward and ability to participate in the treatment process.
Client record #3 was missing client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment, client assets/strengths or other factors that can contribute to the resolution of identified problems, potential or available client support systems, and the client's preferred coping mechanisms.
Client record #4 was missing potential or available client support systems and the counselor's conclusions regarding the client's attitude toward and ability to participate in the treatment process. Additionally, client record #4 identified client's preferred coping mechanisms as "using drugs and my children".
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Plan of Correction
Additional inservice training will be provide by the staff development department by October 31, 2008 on psyhcosocial evaluations. Staff will recieve additonal supervision focused on this area by the clinical supervisor, charts will be monitored on a monthly basis to ensure compliance and that the deficiency does not continue. |
711.52(c)(2) LICENSURE Type/Frequency of TX
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of four client records on August 21, 2008, the facility failed to document frequency of treatment and rehabilitation services in two of four client records.
Findings:
The facility did not document the frequency of treatment and rehabilitation services in client records # 2 and 3.
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Plan of Correction
Additonal training on treatment planning will be provided by the Staff development department on or before October 31, 2008. Staff will be provided copies of the Addiction treatment planner as resource for writing measurable treatment plans and the clinincial supervisor will provide montly review on an ongoing basis to ensure compliance with indicating freguency of service. |
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 on August 21, 2008, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan for two of four records reviewed.
Findings:
The facility failed to document weekly individual sessions as indicated by the individual treatment and rehabilitation plan for client records # 1 and 4.
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Plan of Correction
The clinical supervisor will monitor services provided on a monthly basis during treatment team meetings by reviewing the chart to ensure that individual sessions and all other services are provided in occurance to the treatment plan. Increased monitoring of this issue will begin immediately and be ongoing. |
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 on August 21, 2008, 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 client records.
Findings:
The consent to treatment form documented in client records # 1, 2, 3, and 4 misinformed clients of the need for an informed and voluntary consent to release information relative to homicidal ideation. There was no mention of the need to obtain a court order, in accordance with the federal regulations at 42 C. F. R. Part 2, Subpart E, Subsection 2.63, when releasing information without client consent in order to warn a third party. Additionally, the consent to release information signed by the clients in client records # 1, 2, 3 and 4, did not allow for verbal revocation of the consent to release information.
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Plan of Correction
The Confidential Information section of the consent to treatment form will be revised. This revision will be completed by 9/30/2008. This will be completed under the direction of the Director of Residential Services, the VP of Behavioral Medicine and the Director of Patient/Client Access. These items will be added to the consent 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. |