INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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 November 26, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records, the facility failed to document feedback on completed training for the January 2006 to December 2006 training year in three of four records reviewed, #1, 2, and 4.
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Plan of Correction
Training feedback forms were initited in January 2007 and will be available for all training sessions during training year January-December 2007 and beyond. The Program Director and or his disignee will monitor for compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of training records, the facility failed to document 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment in one of two records reviewed, #4.
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Plan of Correction
TB/STD training is offered on a monthly basis; the staff member who had no documented training will be scheduled to attend training on December 11, 2007. The Program Director will monitor training records on a quarterly basis to ensure compliance with training regulations. |
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 the review of the fire drill record, the facility failed to document which exits were used during the fire drills for the past nine months.
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Plan of Correction
In service training on the accurate completion of fire drill logs will be provede by the saftey office to all staff on or before December 31, 2007. These logs include the designation of the exit route used during the drill and will doucment alternate routes. The Program Director will monitor on a monthly bsis the accurate completion of the form. |
711.51(b)(3)(ii) LICENSURE D&A History
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of the client records, the facility failed to document a complete drug and alcohol history in three of five client records reviewed, #1, 3 and 5. The drug and/or alcohol history did not document the entire length and patterns of use and failed to document the client's perception of the effect on his/her social, physical and mental state.
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Plan of Correction
The hospital compliance committee will review and update the psychosocial history to provide detail on clients percetptions of drug use and lengths and patterns on or before December 20, 2007. The form will provide detail as to clients perception of the affect of use on social, physical and mental state. Inservice training will be provided by the Director of Residential Services on the updated forms. The Program Director will monitor on a monthly basis for accurate completion. Full implementation of the new forms will take place January 1, 2008. |
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 complete psychosocial evaluation in five of five client records reviewed, #1, 2, 3, 4 and 5. Psychosocial evaluations did not include an assessment of the client's assets/strengths, preferred coping mechanisms or negative factors that may inhibit treatment.
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Plan of Correction
Inservice training will be provided to the clinicians by the Director of Residential Services by December 31, 2007 regarding the accurate completion of psychosocial evaluations. Effective immediately the Program Director will increase clinical supervision to twice a month to review and monitor psychosocial evaluations. |
711.52(c)(1) LICENSURE Treatment goals
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:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document treatment plan goals with measurable criteria in three of five records reviewed, #1, 2 and 5.
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Plan of Correction
Inservice training regarding treatment planning will be provided by the education department on or before February 1, 2008. Effective immediately increased clinical supervision will be provided by the Program Director who will monitor the doucmentation of mesurable goals and objectives. |
711.53(a)(4) LICENSURE Progress Notes
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on a review of client records, the facility failed to document complete individual progress notes in two of five client records reviewed, #4 and 5. Progress notes did not included an assessment based upon both new and previous information which includes the counselor's analysis of and conclusions regarding the client's current situation or status and did not include a plan that reflects the counselor's actions to be taken in light of the evaluation and indicate the direction treatment and include action steps, counselor plan(s) and client assignments or task.
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Plan of Correction
Inservice training will be provided by the Program Director on or before December 15, 2007 regarding the progress note process including the documentation of clinical interventions, the assessment of care and plans. The Program Director will monitor progress notes on a monthly basis. |