INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Methadone Monitoring conducted on September 10, 2019 to September 12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
The facility failed to provide one FTE primary care staff person for every seven clients during primary care hours, based on the review of the facility's Staffing Requirement Summary Report.
On 09/01/2019, the census at the facility was 15 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00am-7:00am, there were two staff available during these hours.
8:00am-9:00am, there were two staff available during these hours.
6:00pm-7:00pm, there were two staff available during these hours.
8:00pm-12:00am, there were two staff available during these hours.
On 09/05/2019 the census at the facility was 19 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00am-7:00am, there were two staff available during these hours.
8:00pm-11:00pm, there were two staff available during these hours.
On 09/06/2019 the census at the facility was 19 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00am-7:00am, there were two staff available during these hours.
6:00pm-7:00pm, there were two staff available during these hours.
8:00pm-11:00pm, there were two staff available during these hours.
On 09/07/2019 the census at the facility was 17 clients. This required three primary care staff to be available during primary business hours. The facility was out of ratio during the following times:
12:00am-7:00am, there were two staff available during these hours.
5:00pm-7:00pm, there were two staff available during these hours.
8:00pm-11:00pm, there were two staff available during these hours.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program is hiring 2 additional FTE's(CRNP) for overnight overage to comply with 7:1 staffing ratio. One CRNP will start on October 21, 2019. Until all of the staff is in place and LPN will be assigned overnight whenever the census exceeds 14.
The VP of nursing and Nursing Supervisor will be responsible for reassigning staff in the evening.
Compliance will begin immediately. |
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
The facility failed to identify, on their fire drill log, the amount of time it took for evacuation, the exit route used, and the number of persons in the facility at the time of the drill for every fire drill conducted from October 2018 to August 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Log was updated on 9/12/19 to include the amount of time it takes for evacuation, the exit route used and the number of persons in the facility at the time of the drill.
The new log will be fully implemented by 10/30/19.
The IS3 facility director is responsible for completing the log and the NPHS safety office is responsible for reviewing on a monthly basis. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to develop, and make available to the public, their 2018 annual report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No annual report for FY 2018 was completed because of the prior bankruptcy status of the institution.
The Sr. Vice President will complete and annual report for fiscal year ending June 30, 2019 by November 30, 2019.
Annual Report will be posted on the website by December 15, 2019 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No audit was completed for FY2018 because of the prior bankruptcy status of the organization.
The CFO is responsible for obtaining an audit for FY2019 and has engage a company to complete the audit.
Anticipated date of audit completion: December 30, 2019 |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 12 client records reviewed.
Client #7 was admitted to the inpatient non-hospital level of care on November 30, 2018 and was active at the time of the inspection. There was documentation of a letter to a physician, that identified the client as a member of the drug and alcohol facility, dated August 26, 2019; however, there was no consent to release information form to the physician on file prior to the disclosure.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent form in 2 of 12 client records.
Client # 8 was admitted to the inpatient non-hospital level of care on May 29, 2019 and was active at the time of the inspection. There was a consent to release information form signed and dated by the witness on August 10, 2019; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure would be made to. Additionally, there was a consent to release information form signed by the client on the "Family member consent template"; however, the form did not specify the name of the family member.
Client # 9 was admitted to the inpatient non-hospital level of care on June 25, 2019 and was active at the time of the inspection. There was a consent to release information form signed and dated by the client on July 22, 2019; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure would be made to.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to include the specific information that was to be disclosed on a consent to release information form in 2 of 12 client records.
Client # 8 was admitted to the inpatient non-hospital level of care on May 29, 2019 and was active at the time of the inspection. There was a consent to release information form signed by the client on the "Family member consent template"; however, the consent form did not include the specific information to be disclosed.
Client # 9 was admitted to the inpatient non-hospital level of care on June 25, 2019 and was active at the time of the inspection. There was a consent to release information form signed and dated by the client on July 22, 2019; however, the consent form did not include the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on the consent form in 2 of 12 client records.
Client # 8 was admitted to the inpatient non-hospital level of care on May 29, 2019 and was active at the time of the inspection. There was a consent to release information form signed by the client on the "Family member consent template"; however, the consent form did not include the purpose for disclosure.
Client # 9 was admitted to the inpatient non-hospital level of care on June 25, 2019 and was active at the time of the inspection. There were five consent to release information forms signed and dated by the client on July 22, 2019; however, all of the consent forms did not include the purpose for disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to document the dated signature of a client on a consent to release information form in 1 of 12 client records.
Client # 8 was admitted to the inpatient non-hospital level of care on May 29, 2019 and was active at the time of the inspection. There was a consent to release information form signed and dated by the witness on August 10, 2019; however, the consent form did not include the dated client signature. Additionally, there was a consent to release information form signed by the client on the "Family member consent template"; however, the form did include the date of the client's signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated signature of a witness on a consent to release information form 1 of 12 records.
Client # 8 was admitted to the inpatient non-hospital level of care on May 29, 2019 and was active at the time of the inspection. There was a consent to release information form signed by the client on the "Family member consent template"; however, the consent form did not include the dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide documentation verifying that each client record reviewed had given written acknowledgement that they were informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Patients Rights and Responsibility form were updated on 9/11/19 to include documentation that the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if that director determines that the information may be detrimental if presented to the client.
All active Participants will be provided the new form to sign-copies will be placed in their records and they will be offered a copy of the form.
The VP of Operations updated the form-and will be responsible for insuring that new forms are provided to all new admissions by the intake unit staff.
The clinical Supervisors of the program will be responsible for insuring that all currently active participants are provided with and sign the updated form.
Completion will be by 10/30/19 |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to provide documentation that Client # 10 was notified, in writing, of the reason for the facility's decision to involuntarily terminate the client from treatment. Client # 10 was admitted to the inpatient non-hospital level of care on September 28, 2018 and was administratively discharged on November 17, 2018.
The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Residential Services will review the Administrative Discharge policy with all of the clinical supervisors by 10/15/19.
Clinical Supervisors will review the policy with counseling and nursing staff by 10/30/19.
The clinical supervisors will log all administrative discharges for next 3 months to ensure that notification of intent is given to Participants. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual's identity, including the name, address and date of birth, prior to the administration of a narcotic agent in four of six applicable client records.
Client # 1 was admitted to the inpatient non-hospital detoxification level of care on September 6, 2019 and was active at the time of the inspection.
Client # 3 was admitted to the inpatient non-hospital detoxification level of care on September 6, 2019 and was active at the time of the inspection.
Client # 4 was admitted to the inpatient non-hospital detoxification level of care on November 25, 2018 and was discharged on November 30, 2018.
Client # 6 was admitted to the inpatient non-hospital detoxification level of care on June 21, 2019 and was discharged on June 25, 2019
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
A new identity verification form was developed on 9/12/19 and implemented on 9/16/19 including verification of name, address, and date of birth to be utilized prior the administration of narcotic agents.
Intake staff will be responsible for the completion of the form.
Clinical supervisor will monitor all admission for the next 60 days (completing on 11//30/19) to determine that the form is complete and accurate and will conduct random audits thereafter. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to document if the individual treatment and rehabilitation plan was developed with the client in three of six client records.
Client # 10 was admitted on September 28, 2018 and was discharged on November 17, 2018. The comprehensive treatment plan dated October 19, 2018 did not contain a client signature nor was there any other documentation provided that stated the plan was developed with the client.
Client # 11 was admitted on November 23, 2018 and was discharged on January 30, 2019. The comprehensive treatment plan dated November 23, 2018 did not contain a client signature nor was there any other documentation provided that stated the plan was developed with the client.
Client # 12 was admitted on February 8, 2019 and was discharged on June 4, 2019. There comprehensive treatment plan dated February 8, 2019 did not contain a client signature nor was there any other documentation provided that stated the plan was developed with the client.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will provide in-service training on the completion of treatment plans including the timeliness, requirement for client signatures and documentation of the clinical session during which the treatment plan was completed by October 15, 2019.
The Counselor will be responsible for insuring that client signature and clinical documentation have been completed-Ongoing
The Clinical Supervisor will conduct a focus review of all treatment plans for the next 60 days to insure that signatures and documentation are completed and will review this issue on an ongoing basis during staff supervision. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime 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
The facility failed to provide treatment plan updates within the regulatory timeframe in two of five applicable client records reviewed.
Client # 7 was admitted on November 30, 2018 and was active at the time of the inspection. A treatment plan update was completed on December 7, 2018 with an update was due no later than January 7, 2019; however, the update was not completed until July 30, 2019.
Client # 9 was admitted on June 25, 2019 and was active at the time of the inspection. The comprehensive treatment plan was completed on July 26, 2019 with an update due no later than August 26, 2019; however, there was no update completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide in-service training on the completion of treatment plans including the timeliness, requirement for client signatures and documentation of the clinical session during which the treatment plan was completed by October 15, 2019.
The Counselor will be responsible for insuring that treatment plans are completed on a timely basis-Ongoing
The Clinical Supervisor will conduct a focus review of all treatment plans for the next 60 days to insure that they have been completed on a timely basis and will review this issue on an ongoing basis during staff supervision. |