INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System Return Program 1&2 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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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on a consent to release information form in one of seven client records reviewed.
Client #6 was admitted on April 15, 2021 and was discharged on June 3, 2021. A release of information form to a government agency was signed and dated by the client on April 15, 2021; however, the form did not document the purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
* Clinical supervisor will conduct counseling staff in-service on the purpose of disclosure on a consent form and importance of completing all fields by 11/15/20021.
*Clinical supervisor will focus on monitoring and performing chart audits to insure that all fields are complete for 60 days by reviewing 10 participant files per month.
Responsible Parties:
Clinical Supervisor
Counseling staff
Date of Compliance: 11/15/2021 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving a physical or sexual assault by staff or a client.
The log documented that the incident occurred on June 8, 2021 and was not reported to the Department until June 21, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisors will submit copies of all incident reports to the administrative assistant who will file and forward any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning Oct 18, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: 0ctober 18 , 2021 |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event involving the presence of police, fire, or ambulance personnel.
The log documented that the incident occurred on June 11, 2021 and was not reported to the Department until June 21, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning Oct 18, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: 0ctober 18 , 2021
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