INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-7, 2015, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. 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:
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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 a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure staff persons and volunteers received 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.
The findings include:
The Staffing Requirements Facility Summary Report form was completed by the facility on August 3, 2015. The facility failed to ensure security staff received a minimum of 6 hours of HIV/AIDS and at least 4 hours TB/STD training.
Employee #10, security staff, was hired August 7, 2008. The facility failed to ensure that employee # 10 completed HIV/AIDS & TB/STD training by August 7, 2010.
Employee # 11, security staff, was hired May 13, 2013. The facility failed to ensure that employee # 11 completed HIV/AIDS & TB/STD training by May 13, 2015.
Employee # 12, security staff, was hired May 14, 2012. The facility failed to ensure that employee # 12 completed HIV/AIDS & TB/STD training by May 14, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
* Director of Security will register employee # 10, 11, 12 for HIV/ AIDS & TB/STD training before December 31, 2015
* Director of Security and clinical supervisors will review training hours during monthly individual supervision with each staff member to ensure this deficiency does not recur
* New hires will attend HIV/AIDS & TB/STD training during North Philadelphia Health System orientation.
* All employees will attend mandatory training day each year, where HIV/AIDS & TB/STD updates are discussed
* Director of Security, Training Department, Human Resource and clinical supervisor will be ensure the corrective actions are implemented by December 31, 2015
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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 and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training in five of six personnel records reviewed.
The findings include:
The facility's training year was January 1, 2014 through December 31, 2014.
The facility completed the Staffing Requirements Facility Summary Report form on August 3, 2015, and documented less than 25 clock hours of training on the form for employee # 4, 5, 6, 7 and 9.
Six personnel records were reviewed on August 5, 2015, for documentation of at least 25 clock hours of annual training. The facility failed to ensure that each counselor completed at least 25 clock hours of annual training in personnel records, #4, 5, 6, 7 and 9.
Employee # 4 was hired January 5, 2009, and was required to complete 25 hours of annual training. Employee # 4's training file included documentation of 17 training hours.
Employee # 5 was hired July 9, 2010, and was required to complete 25 hours of annual training. Employee # 5's training file included documentation of 18 training hours.
Employee # 6 was hired December 29, 2010, and was required to complete 25 hours of annual training. Employee # 6's training file included documentation of 7 training hours.
Employee # 7 was hired November 11, 2013, and was required to complete 25 hours of annual training. Employee # 7's training file included documentation of 11 training hours.
Employee # 9 was hired October 14, 2013, and was required to complete 25 hours of annual training. Employee # 9's training file included documentation of 21.5 training hours.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
* Clinical supervisor(s)will meet with employees #4 ,5,6,7,and 9 during supervision and reinforce importance of obtaining 25 education clock annually by September 4, 2015.
* The Director and the Clinical Supervisors will schedule and monitor all trainings to ensure compliance.
* Clinical Supervisor will conduct quarterly reviews of the counselor's training plans to ensure hours are being met. All complete trainings will require a certificate of attendance with the date and hours of training. The counselor will complete a training evaluation to submit with the certificate. Full compliance will be achieved by 12-31-2015. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document the transfer of patient files in patient record #10.
The findings include:
One patient record was reviewed for transfer documentation to a receiving narcotic treatment program on August 5-7, 2015.
Patient #10 was admitted to the facility on March 20, 2014 and transferred on October 9, 2014. The facility failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests and current status of the patient and contain the written consent of the patient.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
1.A in-service will be held on participant transfer procedure on September 7 , 2015 with counseling staff facilitated by clinical supervisor, during treatment team meeting . Policy 715.20 Participant Transfer will be reviewed , during the treatment team meeting .
2.Clinical supervisors will perform chart audit monthly to determine, if policy 715.20 participant transfer procedures are being followed
3.Clinical supervisors will give staff further training in supervision , if need be .
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715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in patient record #10.
The findings include:
One patient record was reviewed for transfer documentation to a receiving narcotic treatment program on August 5-7, 2015.
Patient #10 was admitted to the facility on March 20, 2014 and transferred on October 9, 2014. The facility failed to document what materials were sent to the receiving narcotic treatment program.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
1.A in-service will be held on participant transfer procedure on September 7 , 2015 with counseling staff facilitated by clinical supervisor, during treatment team meeting . Policy 715.20 Participant Transfer will be reviewed , during the treatment team meeting .
2.Clinical supervisors will perform chart audit monthly to determine, if policy 715.20 participant transfer procedures are being followed
3.Clinical supervisors will give staff further training in supervision , if need be .
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to complete the annual physical with a re-evaluation by the narcotic treatment physician in five of nine patient record reviewed.
The findings include:
Nine patient records requiring documentation of an annual physical with a re-evaluation by the narcotic treatment physician were reviewed on August 5-7, 2015. The facility failed to document the annual physical re-evaluation in patient records, #6, 7, 16, 18 and 24.
Patient #6 was admitted to the facility April 8, 2011. The annual physical re-evaluation was due by April 8, 2015. The facility documented the annual physical re-evaluation on May 5, 2015.
Patient #7 was admitted to the facility April 20, 2011. The annual physical re-evaluation was due by April 20, 2015. The last annual physical re-evaluation was completed on June 5, 2014.
Patient #16 was admitted to the facility October 20, 2013. The annual physical re-evaluation was due by October 20, 2014. The facility documented the annual physical re-evaluation on January 16, 2015.
Patient #18 was admitted to the facility June 28, 2010. The annual physical re-evaluation was due by June 29, 2015. The last annual physical re-evaluation was completed on July 13, 2014.
Patient #24 was admitted to the facility February 14, 1997. The annual physical re-evaluation was due by February 14, 2015. The facility documented the annual physical re-evaluation on March 26, 2015.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
1. Medical Director will perform an annual physical policy and procedures in-service during medical staff meeting by September 4,2015.
2. Physician assistant will check Avatar's care plans and compile a list of the upcoming month's participants due for annual physical and revaluations.
3. A message will be placed in Avatar as a reminder to the participant and staff of the physical due date.
4.Check-in clerk notified participant's counselor if physical due date is missed to assure the next appointment is attended.
5. The Medical Director will review, sign and completed annual physicals and re-evaluations.
6. Medical records staff will file physicals and re-evaluations.
7. Clinical supervisor will reviews participant charts and will immediately notify Medical Director of missing annual physical exams or re-evaluations.
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715.26(a) LICENSURE Security
(a) A narcotic treatment program shall meet the security standards for the distribution and storage of controlled substances as required by Federal regulations, including 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls) and State statutes and regulations.
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Observations
Based on a physical plant inspection, the facility failed to store narcotic treatment agents in a locked safe that has been approved by the DEA under 21 CRF 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
The findings include:
A physical plant inspection was conducted on August 7, 2015. Methadone was observed to be stored in a mobile locked cart that is transported to the pharmacy in another building. The methadone cart is stored overnight in the medication area outside of the locked pharmacy. The methadone cart is secured to a handrail with a lock which is equipped with an alarm after hours.
It should be noted that a safe was observed in the dosing area that was not being utilized.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
1. The deficiency will be addressed by storing methadone cart in the night pharmacy effective September 30; 2015.The cart will be monitored overnight by a pharmacist. Methadone cart will no longer be stored outside of the locked pharmacy.
2. Pharmacy, nursing and security staff will transport methadone cart to and from dispensing room daily.
3. The Goldman Clinic will install a video monitoring system to monitor the dosing area. Once the monitoring system is installed and approved by DEA,the medication will be stored inside locked safe located in the nurse?s station.
4. The pharmacy will be responsible for preventing reoccurs of methadone cart being utilized or stored improperly.
5. The Director will be responsible for preventing reoccurs of methadone cart being utilized or stored improperly.
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