INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 2011 through July 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and an interview with the project director, the facility failed to provide documentation for the results of reference investigations in one of ten records reviewed.
The findings include:
On July 14, 2011, ten personnel records were reviewed for documentation of a FBI fingerprint background check in accordance with the Child Protective services Law Act 73. The facility did not provide documentation of a FBI fingerprint background check in personnel record # 11.
Employee # 11 is a residential assistant and was hired on July 21, 2010. However, personnel record # 11 did not include documentation of a FBI fingerprint background check as of July 14, 2011.
During an ongoing dialogue with the project director on July 14, 2011 from approximately 1:00 P.M. to 3:00 P.M., it was confirmed that personal record # 11 did not include documentation of a FBI fingerprint background check.
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Plan of Correction
IHW's Administrative Assistant received FBI finger print background check on employee #11 on 7/15/2011. THe administrative assistant inserted it into employee #11's personnel file. Effective immediately, IHW will not hire an employee without proper clearances (CA/CR, fingerprints).IHW program director in collaboration with PHMC's HR credentialing officer, will perform quarterly personnel chart checks to ensure all employees meet this standard.
On a quarterly basis, the program director and HR credentialing officer will evaluate, review and monitor all employee files to ensure compliance. IHW's administrative assistant will be the person responsible for inserting FBI fingerprint background checks in each employee's file.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedures and an interview with the project director, the facility failed to develop policy and procedures regarding release of information that were consistent with state and federal regulations.
The findings include:
The facility's policy titled: "Disclosure When a Consent is Not Required," states:
"Supervision of Narcotics. Certain agencies, both Federal and State, have a right of immediate access to program records, including the client identifying information. This include-
c. State Drug Law Enforcement Agencies-for inspections respecting the enforcement of criminal laws relating to controlled substances." This policy is in non-compliance with 71 P.S. subsection 1690 .108(b) and 42 CFR part 2, subpart C, subsection 2.31 and 2.32.
An interview with the project director on July 14, 2011 at approximately 9:00 A.M. confirmed that the facility's policy and procedures regarding release of client information were not consistent with state and federal regulations.
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Plan of Correction
Effective 9/17/11, IHW will revise its confidentiality policy when a consent is not needed which currently violates 42CFR. The program director will revise the policy and only release information as outlined in 709.28 "Disclosure when consent is not required." The policy will be approved by the board on 9/16/11. The program director and VP for quality management will hold a staff training to review 709.28 regulations as they pertain to when consent is not needed. The Clinical director will perform a monthly review of the consumer's files to monitor and ensure that the files do not exceed this standard . Adherence will be monitored quarterly by the program director and VP of quality management. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observations on July 14, 2011 and an interview with the facility manager and Clinical Supervisor, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on July 14, 2011. During the inspection, at approximately 12:03 P.M., it was observed that the facility had two dumpsters located in the staff parking lot. Both of the dumpsters were full and were not covered with lids.
An interview with the facility manager and clinical supervisor at approximately 12:04 P.M. confirmed that the dumpsters were full and were not covered with lids.
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Plan of Correction
On 7/15/11 IHW's dumpsters were emptied and the lids replaced by the Allied Waste Services Driver. As part of IHW correction action plan, IHW increased its pick up service agreement with Allied Waste Services to twice a week(Tuesday and Friday). The increase pick up was started on 8/23/11. Effective immediately, all trash will be stored in nonbustible containers with lids. The facility manager will meet with the maintenance person and residential assistant staff to review proper trash storage. The facility manager will perform a daily check to ensure trash in stored properly. Adherence to this standard will be monitored by program director. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the project director and clinical supervisor, the facility failed to document the instruction of staff in the use of the fire extinguishers upon staff employment in one of seven personnel records reviewed.
The findings include:
On July 14, 2011, seven personnel records were reviewed for documentation of fire extinguisher training upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 10.
Employee # 10 is the Facility Psychiatrist and was hired on August 11, 2010. However, personnel record # 10 did not include documentation of fire extinguisher training as of July 14, 2011.
During an ongoing dialogue with the project director and clinical supervisor conducted on July 14, 2011 from approximately 12:15 P.M. to 1:30 P.M., it was confirmed that personal record # 10 did not include documentation of fire extinguisher training.
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Plan of Correction
On 8/23/11, IHW's program pschiatrist(employee #10) had fire extinguisher training provided by the facility manager. On 9/7/11 the program psychiatrist will have a fire extinguisher demonstration training provided by the fire department. Documentation of the fire extinguisher training will be included in employee's personnel file. As part of IHW corrective action plan, the clinical director will develop an employee mandatory training grid. The grid will be used to document and ensure that all employees receive the required trainings, which include fire extinguisher training, needed for their positions. The clinical director will be responsible for ensuring that all staff meet their required trainings as outlined by the Department of Health. The program director will meet with clinical director on a monthly basis to monitor and ensure compliance. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and an interview with the project director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of seven personnel records reviewed.
The findings include:
On July 12, 2011, seven personnel records were reviewed to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in personnel record # 10.
Employee # 10 is the Facility Psychiatrist and was hired on August 11, 2010. However, personnel record # 10 did not include documentation of emergency training as of July 14, 2011.
During an ongoing dialogue with the project director and clinical supervisor conducted on July 14, 2011 from approximately 12:15 P.M. to 1:30 P.M., it was confirmed that personal record # 10 did not include documentation of emergency training.
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Plan of Correction
IHW's program pschiatrist(employee #10) will have emergency training on 9/7/11. The Clinical Director will ensure that the program psychiatrist receives the training. Documentation of this training will be inserted in employee's personnel file by the administrative assistant. As part of IHW corrective action plan, the clinical director will develop an employee mandatory training grid. The grid will be used to document and ensure that all employees receive the required trainings, which include emergency training, needed for their positions. The program director will meet with clinical director on a monthly basis to monitor and ensure compliance.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and an interview with the clinical supervisor, the facility failed to document a physical examination in accordance with the facility's policy and procedures in four of four client records reviewed.
Also, based on a review of client records and an interview with the clinical supervisor, the facility failed to document a physical examination that includes vital signs, review of organ systems, general appearance, and physician's impressions in one of four client records reviewed.
The findings include:
On July 14, 2011, four client records were reviewed for documentation of a physical examination. The facility did not document a physical examination in accordance with the facility's policy and procedures in client records # 1, 2, 3, and 4. Also, the facility did not document a physical examination that includes vital signs, review of organ systems, general appearance, and physician's impressions in client record # 3.
The facility's policy titled: Addiction Services Medical Admissions," states:
"PHMC's Addiction Services Programs provides a comprehensive physical and psychological assessment to all clients at admission. The program physician or the client's PCP completes the physical examination. Physical examinations are to be completed within 24 - 48 hours of admission. The physical examination must include, but is not limited to the following procedures:
1) Medical/Family histories
2) Routine vital signs, including B/P, P,R,T
3) Unclothed physical examination, review of organ systems
4) Tuberculin Skin Test (Mantoux-PPD)
5) Laboratory Screening-Complete blood count and differential
6) Chemistry, GC Culture, RPR (shyphills), Routine Urinalysis
7) Urine Drug Screen
8) Hepatitis A-B profile
9) GYN Services
10) Hepatitis A & B profile
11) Urine Pregnancy Test
Client # 1 was admitted February 17, 2011. However, the physical examination was not completed until June 30, 2011.
Client # 2 was admitted June 3, 2011. However, the physical examination was not completed until June 14, 2011.
Client # 3 was admitted February 21, 2011. However, the physical examination was not completed until March 30, 2011. Also, the physical examination did not include documentation of whether or not a physician completed the physical examination. In addition, the physical examination did not include the client's vital signs, a review of organ systems, a general appearance of the client, and a physician's impressions of the client.
Client# 4 was admitted June 10, 2011. However, the physical examination was not completed until June 30, 3011.
During an ongoing dialogue with the clinical supervisor conducted on July 14, 2011 from pproximately 12:30 P.M. to 3:15 P.M., it was confirmed that the physical examination in client records # 1, 2, 3, and 4 were not documented in accordance with the facility's policy and procedures. Also, during the same ongoing dialogue with the Clinical Supervisor, it was confirmed that the physical examination in client record # 3 did not include vital signs, review of organ systems, general appearance, and physician's impressions.
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Plan of Correction
Client #1, 2, 3, 4 will have a new physical examinations provided by IHW's nurse practioner by 9/17/11. In addition IHW's physical examination policy will be revised to allow 30 days for the program to secure a physical examination. The policy will be presented to the board for approval on 9/15/11. All physicals will include vital signs, review of organ systems, general appearance and provider's impressions. The nursing office will schedule all appts within 30 days of intake. The Nursing supervisor will ensure compliance by performing monthly medical chart audits. The program director monitors compliance quarterly through supervisions with the nursing staff.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records and an interview with the clinical supervisor, the facility failed to document follow-up information in accordance with the facility's policy and procedures in one of three records reviewed.
The findings include:
On July 14, 2011, three records were reviewed for documentation of follow up information. The facility did not document follow-up information according to their policy and procedures on follow-up information in client record # 5.
The facility's policy titled: "Follow Up Policy," states:
"All clients who completed treatment at the Interim House West will receive a follow up phone call within one week and again at six month after program completion and/or discharge. Documentation of all one week and six-month contacts are placed in a follow manual located in the case manager's office. A copy is maintained in the client file."
Client # 5 was admitted December 20, 2010 and was discharged June 20, 2011; however, the follow-up information did not include a date the follow up was completed.
During an ongoing dialogue with the clinical supervisor conducted on July 14, 2011 from approximately 3:00 P.M. to 4:00 P.M., it was confirmed that the facility did not document follow-up information in accordance with the facility's policy and procedures in client record # 5.
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Plan of Correction
On 7/18/11, CM completed the follow up on client # 5. As part of IHW, corrective action plan, the case management supervisor will meet with the case managers to ensure that all 7 day follow ups are being done within one week. The supervisor will also emphasize the importance of fully completing the 7 day(one week) follow up form to include signature, date and time of the contact. The case manager's supervisor and clinical director will review the charts and monitor follow up compliance on a montly basis.
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