INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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 October 24, 2009.
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on the review of personnel records, the facility failed to either document training plans or documented them late in seven of twenty-one personnel records reviewed.
The findings include:
Twenty-one personnel records were reviewed on September 17, 2009. Training plans were required in twenty-one personnel records. Per the facilities policy and procedure, training plans will be developed by January 31 of each year. Records 2, 7, 11, 15 and 16 were documented late. Employee #2's was hired on 10/02 and their training plan was completed on 2/2/09. Employee #7's was hired 8/07 and their training plan was completed on 4/27/09. Employee #11's was hired 6/06 and their training plan was completed on 2/2/09. Employee #15's was hired 4/07 and their training plan was completed on 2/2/09. Employee #16's was hired 12/08 and their training plan was completed on 2/2/09. Training plans were not documented in records #3 and 12. Employee #3 was hired at current position on 11/07 and as of to date no training plan documented in personnel record. Employee #12 was hired at current position on 8/08 and as of to date no training plan documented in personnel record.
|
Plan of Correction
By October 30, 2009, the Goldman Clinic Supervisors and Program Director will review all personnel files to ensure all training plans have been completed and filed in each personnel file. The Clinical Supervisors together with the Program Director will be responsible for completing training plans in a timely basis. The Goldman Clinic Program Director will review all personell files on a quarterly basis to assure that all individualized training plans and needs assessments are completed on a timely basis. |
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.
|
Observations
Based on a review personnel record, the facility failed to make sure that all staff are trained for 6 hours in HIV/AIDS and at least 4 hours of TB/STD training in the required amount of time in two of twenty-one records reviewed.
Findings:
Twenty-one personnel records were reviewed on September 17, 2009. Employee # 11 was hired June 2006 and is required to have HIV/AIDS & TB/STD training by June 2007 and as of September 17, 2009 did not have the required trainings. Employee #12 was hired August 2002 and is required to have TB/STD training by August 2003 and as of September 17, 2009 did not have the required training. There was no documentation of the trainings in the personnel record reviewed.
|
Plan of Correction
Twenty-one personnel records were reviewed on 9/17/09; two employees were missing required trainings. Employee #11 will be scheduled to attend HIV training by December 31, 2009. Employee #12 has completed TB/STD training and the certificate of completion has been filed in the personnel file. Clinical Supervisors will be conducting quarterly reviews to monitor for required training hours needed by each employee. This process will be enforced by the Program Director. The Program Director will conduct random personnel file reviews to ensure 100% compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure and document that counselors completed at least 25 hours of training for the training year 2008 in three of fifteen personnel records.
Findings:
Twenty-one personnel records were reviewed on September 17, 2009. Twenty-five training hours were required to be documented in four personnel records, two were in compliance and fifteen others were new hires. State standards states that counselors must completed 25 hours of training annually. This was not documented in personnel records #7, 11 and 12. Employee #7 only had 20 hrs worth of training for the training year 2008. Employee #11 only had 14 hrs worth of training for the training year 2008. Employee #12 only had 7 hrs worth of training for the training year 2008.
|
Plan of Correction
By September 30, 2009, the Goldman Clinic Program Director will have completed a review of training hours needed by each employee. During team meeting of September 30, 2009, all employees were informed by the Clinical Supervisors of their training hours needed. We began the process of scheduling employees for internal and external trainings. The training hours will be completed under the supervision of the Goldman Clinic Supervisors and the Department of Education at NPHS. Supervisors will be conducting quarterly reviews of the personnel files to ensure employees are reaching their 25 hours of training. The Program Director will follow up with Supervisors on a quarterly basis to ensure that all employees attend trainings as scheduled. On a quarterly basis, the Program Director will be conducting 100% review of all personnel files to assure we achieve 100% compliance. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a tour of the facility ' s physical plant, the facility failed to ensure privacy so that counseling sessions could not be seen outside the counseling room.
The findings include:
A tour of the facility ' s physical plant was conducted on September 23, 2009 at approximately 9:30 AM. There were two individual counseling offices and one group counseling room where the window shades were not closed during counseling sessions to ensure privacy.
Counseling sessions could be observed outside of counselor offices # 230 and 231 and one of the group rooms.
|
Plan of Correction
On 9/21/09 during team meeting, all employees were addressed about the responsibility of client's comfort, confidentiality, and privacy during group and individual sessions. By 9/30/09, signs have been posted on all group rooms as a reminder of client's privacy and confidentiality. Clinical Supervisors are responsible for conducting daily rounds to ensure ongoing compliance of this process. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to complete psychosocial evaluations in five of six client records.
Findings:
Eight client records were reviewed on September 22, 2009. Psychosocial evaluations were required in six client records. The counselors did not evaluate the client's when it came to the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselors conclusion/impressions of the client in client records #2, 4, 5, 6. Also, in client record #3 the psychosocial evaluation was illegible.
|
Plan of Correction
On 10/26/09, Clinical Supervisors will conduct an in-service on how to properly complete psycho-social evaluations. Two other in-services will be scheduled during the months of November and December of 2009. Any psycho-social not meeting the standards on 705.4(3) will be returned to the counselors for corrections. Psycho-social evaluations not legible will be typed by the counselor. Clinical Supervisors will be responsible for conducting chart reviews during weekly supervision and at random to ensure proper documentation is being completed. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on the review of client records, the facility failed to provide services according to the individual treatment plan in three of six client records.
The findings include:
Eight client records were reviewed on September 22, 2009. Client record #1 treatment plan dated 7/9/09 stated that the client was to have group daily and individual weekly. There were not documentation of group notes in record #1. Client record #2 treatment plan dated 8/5/09 stated that the client was to have group daily and individual weekly. There was not documentation of group notes or documentation of individual notes in record #2. Client record #4 treatment plan dated 3/21/09 sated that client was to have group daily and individual weekly. Documentation on the record of service showed that client came in 4/8/09, 5/12/09, 8/26/09 and 9/9/09 show a gap in service for individual session and group session in record #4.
|
Plan of Correction
Effective immediately and thereafter, the Clinical Supervisors will monitor that services provided are being provided according to the individualized treatment plan. Clinical Supervisors will be reviewing charts during weekly supervision and at random to ensure that individualized session groups are being provided as specified in the treatment plan. Clinical Supervisors will monitor this process by conducting weekly and random chart reviews. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. 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 in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in two of four discharge client records.
Findings:
Eight client records were reviewed on September 23, 2009. Follow-up information was required in three discharge client records. Per facilities policy follow-ups will be done 30 days after discharged if not being referred. Client #6 was discharged on 7/29/09 and follow-up was to be documented by 8/29/09 and this was not documented in client record reviewed. Client #7 was discharged on 8/12/09 and follow-up was to be documented by 9/12/09 and this was not documented in client record reviewed.
|
Plan of Correction
The Clinic Coordinator will complete follow up information 30 days after a discharge occurs. This process will be completed under the supervision of the Clinical Supervisors. The Clinical Supervisors will provide quarterly reviews on discharged records to ensure compliance of the 30 day follow up. The Program Director will also review five discharged records on a quarterly basis to guarantee the process is being completed as scheduled. |