INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, North Philadelphia Health System - Return Program 1&2 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in four of seven client records reviewed.
Client # 1 was admitted on March 16, 2021 and was still active at the time of inspection. The written procedure manual stated that case consultations will be completed at least monthly and documented in a treatment team note. There was no documentation of a case consult or treatment team note in the client record at the time of inspection.
Client # 2 was admitted on March 27, 2021 and was still active at the time of inspection. The written procedure manual stated that case consultations will be completed at least monthly and documented in a treatment team note. There was no documentation of a case consult or treatment team note in the client record at the time of inspection.
Client # 5 was admitted on March 21, 2020 and was discharged on May 11, 2020. The written procedure manual stated that case consultations will be completed at least monthly and documented in a treatment team note. There was no documentation of a case consult or treatment team note in the client record for the month of April 2020.
Client # 6 was admitted on June 18, 2020 and was discharged on August 8, 2020. The written procedure manual stated that case consultations will be completed at least monthly and documented in a treatment team note. There was no documentation of a case consult or treatment team note in the client record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
* The Clinical Supervisor will initiate a training during monthly staff meetings to address case consultations that will be completed at least monthly and documented in a treatment team note of all clients receiving treatment. The initiated training will begin by June 15 , 2021. |
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
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed.
Client # 3 was admitted on March 30, 2021 and was still active at time of inspection A release of information form to a government agency was signed and dated by the client on April 15, 2021 that allowed for the release of psychiatric evaluations, psychosocial history, copies of progress notes, history and physical exam, and results of UDS, all of which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the September 18, 2019 annual renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
*The Clinical Supervisor to ensure conformance with DDAP regulations with specific attention to Counselor checking off the appropriate boxes for information to be released to agencies and individuals. An In-Service training will be provided during unit staff meetings by June 9 , 2021. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a physical or sexual assault by staff or a client.
On March 17, 2021, there was a physical or sexual assault by staff or client that occurred; however there was no documentation that this incident was reported to the Department at the time of the inspection.
This is a repeat citation from the September 18, 2019 annual renewal inspection.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
*Incident reports will be submitted for all incidents noted in the citation by the administrative assistant of the Program by June 4, 2021.
Responsible party-Administrative Assistant
Date of compliance 6-4-2021
Beginning June 1, 2021 Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning June 1, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: June 4, 2021
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
On October 12, 2020, an emergency medical team was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department at the time of the inspection.
On February 25, 2021, an emergency medical team was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department at the time of the inspection.
On April 27, 2021, an emergency medical team was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department at the time of the inspection.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
*Incident reports will be submitted for all incidents noted in the citation by the administrative assistant of the Program by June 4, 2021.
Responsible party-Administrative Assistant
Date of compliance 6-4-2021
Beginning June 1, 2021 Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning June 1, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: June 4, 2021
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709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to properly document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan in three of seven client records reviewed.
Client # 2 was admitted on March 27, 2021 and was still active at time of inspection. The comprehensive treatment plan was completed on April 5, 2021; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on March 30, 2021 and was still active at time of inspection. The comprehensive treatment plan was completed on April 5, 2021; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on November 29, 2019 and was discharged on January 9, 2020. The comprehensive treatment plan was completed on December 6, 2020; however, the plan did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
* Clinical supervisor will review Client#2 , Client#3 and Client# 4 with assigned counselor(s)to discuss importance of properly document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan
* The Clinical Supervisor will train all of the clinical staff on how to include in the treatment plans, the type and frequency of treatment and rehabilitation services.
*Clinical Supervisor will conduct random audits of three(3)charts per clinician each month to validate that staff by members properly document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan by June 15, 2021 and ongoing review of charts. |