INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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. The following deficiencies were identified during this inspection:
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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
The facility failed to provide documentation of an annual individual training plan for the current training year, which is to be developed with input from both the employee and the supervisor in two of five personnel records reviewed.
Employee # 2 was hired at the facility on December 13, 2010 and promoted to the Facility Director on September 17, 2018. The most recent individual training plan was signed by the employee and supervisor on January 17, 2018.
Employee # 4 was hired at the facility on June 30, 2004 and then as a counselor on July 1, 2019. The most recent individual training plan was signed by the employee and supervisor on January 29, 2018.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
A 2019 training plan was developed for employee 2 and 4 on 10/30/19.
The Clinical Supervisor and office manager will monitor on an ongoing basis new hires for the development of treatment plans within 30 days of hire or promotion. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills each month during the review period of September 2018 through August 2019.
This finding was reviewed with facility staff during the licensing process
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Plan of Correction
The Fire Drill Log was updated on 9/12/19 to include the amount of time it takes for evacuation, the exit route used and the number of persons in the facility at the time of the drill.
The new log will be fully implemented by 10/30/19.
The IS3 facility director is responsible for completing the log and the NPHS safety office is responsible for reviewing on a monthly basis.
The NPHS safety office will monitor fire drill log on a monthly basis to insure that unannounced drills occur.
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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
The facility failed to develop, and make available to the public, their annual report for the 2018 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No annual report for FY 2018 was completed because of the prior bankruptcy status of the institution.
The Sr. Vice President will complete and annual report for fiscal year ending June 30, 2019 by November 30, 2019.
Annual Report will be posted on the website by December 15, 2019
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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
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
No audit was completed for FY2018 because of the prior bankruptcy status of the organization.
The CFO is responsible for obtaining an audit for FY2019 and has engage a company to complete the audit.
Anticipated date of audit completion: December 30, 2019
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed.
Client # 6 was admitted on October 19, 2018 and was discharged on December 21, 2019. The record contained a consent to release information form to the funding source, signed and dated by the client on October 24, 2018, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5. The information to be released included the release of psychiatric evaluations, psychosocial histories, progress notes, history and physical exam and the results of urine drug screenings.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms including the limits established by 4 Pa. Code 255.5 with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion
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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
The facility failed to provide documentation that verified that the client had given written acknowledgement that they were informed that when they are receiving care or treatment under section 7 of the act (71 P. S. 1690.107), they shall retain all their civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in two of seven client records reviewed.
Client # 1 was admitted on January 15, 2019 and was active at the time of the inspection.
Client # 3 was admitted on October 16, 2018 and was discharged on February 13, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation that the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental if presented to the client.
All active Participants will be provided the new form to sign-copies will be placed in their records and they will be offered a copy of the form.
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
The clinical Supervisors of the program will be responsible for insuring that all currently active participants are provided with and sign the updated form.
Completion will be by 10/30/19
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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to provide documentation verifying that the client had given written acknowledgement that they were informed that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in two of seven client records reviewed.
Client # 1 was admitted on January 15, 2019 and was active at the time of the inspection.
Client # 3 was admitted on October 16, 2018 and was discharged on February 13, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation of the following:
1. That the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental;
2. That the client had given written acknowledgement that they were informed that they had the right to appeal, to the director, a decision limiting access to their record;
3. That the client had the right to submit rebuttal data or memoranda to their own record;
4. That they had been informed that they had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their own record
5. That the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion
The Clinical Supervisor will be responsible for insuring that all active Participants will be provided the new form to sign that copies are placed in their records and they are offered a copy of the form.
Completion will be by 10/30/19
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
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709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide documentation verifying that the client had given written acknowledgement that they were informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record in three of seven client record reviewed.
Client # 1 was admitted on January 15, 2019 and was active at the time of the inspection.
Client # 2 was admitted on May 20, 2018 and was active at the time of the inspection.
Client # 3 was admitted on October 16, 2018 and was discharged on February 13, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation that the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental if presented to the client.
All active Participants will be provided the new form to sign-copies will be placed in their records and they will be offered a copy of the form.
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
The clinical Supervisors of the program will be responsible for insuring that all currently active participants are provided with and sign the updated form.
Completion will be by 10/30/19
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709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to provide documentation verifying that the client had given written acknowledgement that they were informed that they had the right to appeal, to the director, a decision limiting access to their record in two of seven client record reviewed.
Client # 1 was admitted on January 15, 2019 and was active at the time of the inspection.
Client # 3 was admitted on October 16, 2018 and was discharged on February 13, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation of the following:
1. That the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental;
2. That the client had given written acknowledgement that they were informed that they had the right to appeal, to the director, a decision limiting access to their record;
3. That the client had the right to submit rebuttal data or memoranda to their own record;
4. That they had been informed that they had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their own record
5. That the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion
The Clinical Supervisor will be responsible for insuring that all active Participants will be provided the new form to sign that copies are placed in their records and they are offered a copy of the form.
Completion will be by 10/30/19
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
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709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The facility failed to provide documentation verifying that the client had given written acknowledgement that they had been informed that they had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their own record in two of seven client records reviewed
Client # 1 was admitted on January 15, 2019 and was active at the time of the inspection.
Client # 3 was admitted on October 16, 2018 and was discharged on February 13, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation of the following:
1. That the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental;
2. That the client had given written acknowledgement that they were informed that they had the right to appeal, to the director, a decision limiting access to their record;
3. That the client had the right to submit rebuttal data or memoranda to their own record;
4. That they had been informed that they had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their own record
5. That the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion
The Clinical Supervisor will be responsible for insuring that all active Participants will be provided the new form to sign that copies are placed in their records and they are offered a copy of the form.
Completion will be by 10/30/19
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
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709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The facility failed to provide documentation verifying that the client had given written acknowledgement that they were informed they had the right to submit rebuttal data or memoranda to their own record in two of seven client records reviewed.
Client # 1 was admitted on January 15, 2019 and was active at the time of the inspection.
Client # 3 was admitted on October 16, 2018 and was discharged on February 13, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients' Rights and Responsibility form were updated on 9/11/19 to include documentation of the following:
1. That the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental;
2. That the client had given written acknowledgement that they were informed that they had the right to appeal, to the director, a decision limiting access to their record;
3. That the client had the right to submit rebuttal data or memoranda to their own record;
4. That they had been informed that they had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their own record
5. That the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion
The Clinical Supervisor will be responsible for insuring that all active Participants will be provided the new form to sign that copies are placed in their records and they are offered a copy of the form.
Completion will be by 10/30/19
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
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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
The facility failed to properly document biopsychosocial evaluations in three of seven client records reviewed. Per the facility's policy and procedures manual, the biopsychosocial evaluation was to be completed within 30 days of admission.
Client #5 was admitted on July 24, 2019 and was still active at the time of the inspection. The biopsychosocial evaluation was completed on September 12, 2019.
Client #6 was admitted on October 19, 2019 and was discharged on December 21, 2018. There was no biopsychosocial assessment in the client record.
Client #7 was admitted on March 1, 2019 and was discharged on June 5, 2019. There was no biopsychosocial assessment in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will provide in-service training to all clinical staff regarding the policy regarding the timely completion of bio-psychosocial histories by November 15, 2019.
The clinical supervisor will conduct a focused review of all admissions for 60 days to insure that histories are completed-December 31, 2019
The clinical supervisor will conduct ongoing random reviews of admissions to insure continued compliance.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in two of seven client records reviewed.
Client #3 was admitted on October 16, 2018 and was discharged on February 13, 2019. A treatment plan was completed on October 24, 2018 with the next update due no later than December 24, 2018; However, there was no update completed prior to discharge.
Client #7 was admitted on March 1, 2019 and was discharged on June 5, 2019. A treatment plan was completed on March 5, 2019 with the next update due no later than May 5, 2019; However, there was no update completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide in-service training on the completion of treatment plans including the timeliness of initial plans and updates as well as the requirement for client signatures and documentation of the clinical session during which the treatment plan was completed by October 30, 2019.
The Counselor will be responsible for insuring that client signature and clinical documentation have been completed-Ongoing
The Clinical Supervisor will conduct a focus review of all treatment plans for the next 60 days to insure that signatures and documentation are completed and will review this issue on an ongoing basis during staff supervision.-November 30. 2019
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