INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2011 by staff from the Division of Drug and Alcohol 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:
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Plan of Correction
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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.
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Observations
Based on the review personnel records, the facility failed to document staff individual training plans within 30 days of hire in two of two new hires personnel records reviewed.
The findings include:
On August 8, 2011 through August 9, 2011, two new employee personnel records requiring that the individual training plan be developed within 30 days of the hire date, were reviewed. The facility failed to document individual training plans within 30 days in two of two records reviewed, specifically, #4 and 5.
Employee #4 was hired on December 15, 2010 and their training plan was to be developed by January 15, 2011. Employee #4 training plan was not developed until January 18, 2011.
Employee #5 was hired on May 23, 2011 and their training plan was to be developed by May 23 2011. Employee #5 training plan was not developed until August 1, 2011.
An interview with facility staff on August 19, 2011 confirmed the findings.
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Plan of Correction
The policy regarding training plans will be reviewed with the clinical director. The Clinical director will be responsible for ensuring that the policy is follow-up. The completion on the training plan will be added to the new employee orientation checklist and the Director of residential services will be responsible for monitoring. A focus monitor will take place for the next 60 days of all new hires to ensure compliance. Full compliance will be achieved by 11-30-2011. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that counselors completed at least 25 hours of training for the 2010 training year.
The findings include:
On August 8, 2011 through August 9, 2011, two counselor's personnel records were reviewed to ensure that the counselors completed the required 25 hours of training for the 2010 training year. The facility failed to ensure that one of two counselors completed 25 hours of training for the 2010 training year, specifically employee #3.
Employee #3 was hired July 9, 2007 and was required to have obtained 25 hours of training for the 2010 training year. Employee #3 only had 12 hours of training documented for training year 2010.
A discussion with facility staff on August 19, 2011 confirmed that the required training hours was not obtained for training year 2010.
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Plan of Correction
The clinical superviosr will review training records on a quarterly basis to ensure that staff are obtaining required training hours. Full compliance will be obtained by December 31, 2011. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility safe and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
An inspection of the facility ' s physical plant was conducted on August 18, 2011 between approximately 8:30 AM and 11:00 AM. The employee and visitors' parking lot was unsafe and in poor condition at the time of inspection.
The parking lot was unsafe due to the asphalt being uneven and having many potholes. Because of the size and number of potholes, it is hazardous to walk in the parking lot, and it is also impossible for drivers to avoid the potholes when driving in the parking lot.
The findings were confirmed by the facility director on August 18, 2011.
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Plan of Correction
NPHS has obtained bids on the repair of the parking lot. The repair will be completed on or before 10/31/11. The CEO is reponsible for authorizing and ensuring repair. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
An inspection of the facility's physical plant was conducted on August 18, 2011 between approximately 8:30 AM and 11:00 AM. The facility did not ventilate one of the two unisex wash rooms in the waiting area on the third floor.
The findings were confirmed by the facility director on August 18, 2011.
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Plan of Correction
This deficieny was corrected prior to the end of the survey. Environmental rounds will be completed on a montly basis to ensure ongoing compliance with this policy. The unit administration will be responsible for ensuring that rounds are conducted. Full compliance will be obtained by 9/30/11. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in accordance with facility policy to include a composite picture of the individual in relationship to the collected historical information and/or facility time frames.
The findings include:
On August 18, 2011, eight client records requiring psychosocial evaluations were reviewed.
The facility did not document a psychosocial evaluation to include a composite picture of the individual in relation to the collected historical information, as per facility policy, in eight of eight client records reviewed, specifically, # 1, 2, 3, 4, 5, 6, 8 and 9.
The facility's policy titled "Bio-Psychosocial" states:
"Within the first thirty days, the Counselor completes:
The Psychosocial History and Evaluation - this provides a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation."
Client # 1 was admitted on 3/9/11. The psychosocial evaluation in client record # 1 dated 3/10/11 did not include the client's problems, assets and strengths, coping mechanisms, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 2 was admitted on 5/17/11. The psychosocial evaluation in client record # 2 dated 5/17/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 3 was admitted on 5/26/11. The psychosocial evaluation in client record # 3 dated 6/3/11 did not include the client's support systems, coping mechanisms, negative factors, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 4 was admitted on 12/16/10. The psychosocial evaluation in client record # 4 dated 1/18/11 did not include the client's problems, assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 5 was admitted on 4/21/11. The psychosocial evaluation in client record # 5 dated 5/10/11 did not include the client's assets and strengths, coping mechanisms, negative factors, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The findings were confirmed by the facility director on August 18, 2011.
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Plan of Correction
Small group instruction in evaluation/case formulation will be conducted by the education department in cooridnation with the Chief of psychology. All clinical staff will participate in the training. All clinical staff will complete retraining by October 31, 2011. Supervision sessions conducted by program managers over the next 90 days will focus on evaulations. |