INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 23, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on September 24, 2010.
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Plan of Correction
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a tour of the facility ' s physical plant and an interview with the facility director, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The facility was required to ventilate all toilets and wash rooms by exhaust fan or window. The facility did not ventilate the wash room in client bedroom #716 on the 7th floor of the Tower Building.
The facility director confirmed that ventilation was not provided in the identified wash room.
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Plan of Correction
All the vent motors were replaced during the survey. The Director of Plant Facilities will place the monitoring of vent motors as a part of the monthly preventative maintenance rounds.Fully compliance August 26, 2010.
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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 facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
The facility fire drill record did not include any record of a fire drill for June 2010.
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The staff person questioned confirmed that there was no documentation of a June 2010 Fire drills, nor were there any observation sheets completed for December 31, 2009.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The fire drill conducted on November 27, 2009 failed to document the exit route used.
The fire drill conducted on January 18, 2010 did not identify the exit route.
The fire drill record of February 25, 2010 only contained documentation for the ninth floor of the Tower building.
The fire drill conducted on April 6, 2010 did not include the number of participants.
The fire drill conducted on May 26, 2010 had a note that the indicated no evacuation due to early morning.
The staff person questioned confirmed the findings.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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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 client records, the facility failed to document a psychosocial evaluation to include the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions in five of six client records reviewed.
The finding includes:
Six records were reviewed on August 23, 2010 through August 24, 2010. Psychosocial evaluations were required in six records reviewed.
Client records #1 and 3 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions.
Client records #4 failed to document the client's assets/strengths, support systems, coping mechanisms, client attitude toward treatment and the counselor conclusions/impression.
Client records #5 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impression. .
Also, client record #6 failed to have documentation of the clients psychosocial evaluation in record reviewed. Per the facility's policy and procedure psychosocial evaluations will be completed within 30 days of admission. Client record #6 was admitted on 3/30/10 and discharged on 6/17/10.
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Plan of Correction
The Director of Outpatient Psychiatry will develop a three hour training sessions on completing psychosocial evaluations and will provide the training to all clinical staff by November 30, 2010.
A psychologist from the Outpatient Department will conduct random reviews of evaluations and meet with clinical staff to review case formulations/evaluations for the next 90 days.
The clinical supervisors will review three cases per month of each clinician for the next 90 days, focusing on psychosocial evaluations.
Ongoing monitoring will be conducted by the clinical supervisors and full compliance will occur by December 31, 2010.
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711.58(a)(4) LICENSURE Control/accountability of Drugs
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on the review of the facilities medication administration records for clients, the facility failed to maintain accurate records on the individual medications.
The findings include:
Medication administration records were reviewed on August 25, 2010. three of those listed inventory records that were inconsistent.
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Plan of Correction
In service training will be provided to all staff responsible for the self administration of medication by the education department by October 15, 2010.
Revision of the self-administration policy will be completed by September 30, 2010 by the Vice President of Behavioral Health to clarify the responsibility of counting medication as a staff issue. Staff will receive re-education regarding policy by October 15, 2010.
Clinical supervisor will conduct a daily focused monitor of the medication log for the next 45 days to insure compliance. Programs will be fully compliant by October 30, 2010.
On going monitoring will be conducted by the clinical supervisors.
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