INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25 and October 30, 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 - Torre de la Raza 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 training received by employees in three of three records reviewed, #1, 2 and 3.
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Plan of Correction
Training feedback forms were initiated in January 2007 and will be available for all training sessions during training year January -December 2007 and beyond. The division secreatary will attach feedback forms to each training certificate before thet are filed.
The Program Director and or his disegnee will monitor for compliance on a quarterly basis. |
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 administrative documents on 10/25/07, the facility failed to document that alternate exit routes were used during nine of the last nine fire drills.
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Plan of Correction
In service training on the accurate completion of fire drill logs will be provided 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 document alternate routes. The Program Director will monitor on a monthly basis 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 client records on 10/31/07, the facility failed to document a complete drug and alcohol history in five of five client records reviewed, #1, 2, 3, 4 and 5. Substances abused were incomplete in two of five client records reviewed, #1 and 2. The lengths and patterns of use and client's perceptions were missing in five records, #1, 2, 3, 4 and 5.
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Plan of Correction
The hospital compliance committee will review and update the psychosocial history to provide detailed on clients perceptions of drug use and lengths and patterns on or before December 20, 2007. 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 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 on 10/31/07, the facility failed to document a complete psychosocial evaluation in five of five records reviewed, #1, 2, 3, 4 and 5. An assessment of client problems/needs and assets/strengths were missing in three of five records reviewed, #1, 2 and 3. Support systems were missing in two of five records reviewed, #3 and 4. Coping mechanisms were missing in three of five records reviewed, #1, 4 and 5. Negative factors which may inhibit the potential for treatment were lacking a clinical assessment in four of five records reviewed, #1, 2, 3 and 4. The client's attitude toward treatment was missing in two of five client records reviewed, #2 and 3.
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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 supervison 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 on 10/31/07, the facility failed to document goals stated in terms of measurable criteria in five of five client records reviewed, #1, 2, 3, 4 and 5.
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Plan of Correction
Inservice training regarding treatment planning will be provided by the education department on or before January 15, 2008.
Effective immediately increased clinincal supervision will be provided by the Program Director who will monitor the documentation of measurable goals and objectives and provide one on one instruction. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records on 10/31/07, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plans in two of three client records reviewed, #1 and 4.
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Plan of Correction
Effective September 2007 a new treatment plan format was iniatated in all Residential programs. The new format requires the assessment of progress on the prior goals and objectives. The Program Director will monitor the accurate completion of the treament plan in monthly clinical supervision. |