INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System IOP-CAP 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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704.11(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.
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Observations
Based on the review of the facility-submitted Staffing Facility Requirements Summary Report and personnel records, the facility failed to ensure that all staff persons received the minimum of six hours of HIV/AIDS training and four hours of TB/STD training within the regulatory timeframe.
Employee #4 was hired as a counselor on August 10, 2020 and was due to have the HIV/AIDS training and the TB/STD training no later than August 10, 2021; however, there was no documentation of the completion of either training in the record as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On September 30, 2021 and October 1, 2021, Employee #4 completed the HIV/Aids and the TB/STD trainings. Clinical supervisor has included said documentation in employees records. In moving forward, the Clinical Supervisor will review employee files on a quarterly basis, starting November 15, 2021, to ensure that all employees are compliant with required trainings. |
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
Based on a review of client records, the facility failed to document the purpose of disclosure on a consent to release information form in one of seven client records reviewed.
Client #4 was admitted on July 23, 2021 and was discharged on September 7, 2021. A release of information form to a government agency was signed and dated by the client on July 23, 2021; however, the consent form did not document the purpose of disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will provide an in-service by October 15, 2021 for all clinicians on the proper way of completing consent to release information including documenting the purpose of disclosure. In addition, Clinical supervisor will monthly chart audits to ensure that consents are completed properly. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records and the facility's unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident involving the off-site death of an active client.
On September 7, 2021, the facility was notified of the offsite death of client #4, who was admitted on July 23, 2021; however, there was no documentation that the incident was reported to the Department as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will implement new procedure for reporting unusual incident reports within 3 business days, which consists of submitting all incident reports to the Senior VP of Behavioral Health who will then ensure that unusual incident reports are submitted according to regulations. Clinical supervisor will provide training to staff on the new procedure by October 15, 2021. |