INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 28, 2021 through 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 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on September 29, 2021 at approximately 1:30PM, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The bathroom, located in room 425, had a wall with broken drywall and peeling paint.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Director and Clinical services will direct support staff to perform environmental rounds daily to access the physical plant, rounds sheet are will be available for review on unit.
*Clinical supervisor will report to environmental services any physical plant issues i.e. bathroom is not functional, clean and sanitary in a timely manner.
*Clinical supervisor will report to (plant owner) any physical plant issues such as broken drywall and peeling paint timely manner.
*Clinical Supervisor will monitor completion of environmental services and work orders and report results in
Performance Improvement Report
Room 425 repairs were completed on Oct. 19 ,2021
Responsible Parties:
Director
Clinical Supervisor
Residential support staff
Date of Compliance: October 19, 2021
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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
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.
Client # 14 was admitted on May 19, 2021 and was administratively discharged on September 8, 2021. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical Supervisor will provide an in-service training to all staff regarding notification of termination per Policy: 730.114 Involuntary Discharge/ Notification of Intent to Discharge
*Clinical Supervisor will conduct random audits of three (3) charts per clinician each month to validate that staff members are correctly following : Policy 730.114 Involuntary Discharge/ Notification of Intent to Discharge
*Counselor will utilizes intent to terminate form to review and notify participant in writing of involuntary / discharge process
Responsible party- Clinical Supervisor and counselor
Date of compliance 10-19-2021
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 14 was admitted on May 19, 2021 and was administratively discharged on September 8, 2021. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical Supervisor will provide an in-service training to all staff regarding notification of termination per Policy: 730.114 Involuntary Discharge/ Notification of Intent to Discharge
*Clinical Supervisor will instruct counseling staff during in-service to explain reason for giving a intent to discharge and appeal process before signing by participant
*Clinical Supervisor will conduct random audits of three (3) charts per clinician each month to validate that staff members are correctly following : Policy 730.114 Involuntary Discharge/ Notification of Intent to Discharge
Responsible party- Clinical Supervisor and counselor
Date of compliance 10-19-2021
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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 June 2021 through September 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on the following dates:
An incident occurred on June 11, 2021 and it was not reported to the Department until July 1, 2021.
An incident occurred on August 18, 2021 and it was not reported to the Department until September 2, 2021.
An incident occurred on August 21, 2021 and it was not reported to the Department until September 2, 2021.
An incident occurred on August 31, 2021 and it was not reported to the Department until September 15, 2021.
An incident occurred on September 3, 2021 and it was not reported to the Department until September 15, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical supervisors will submit copies of all incident reports to the administrative assistant in a timely manner who will any file and forward 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.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: 10-19-2021
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715.8(1)(i)(A) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(1) General requirements. A narcotic treatment program shall comply with the patient/staff and patient/counselor ratios in subparagraphs (i)-(vi) during primary care hours. These ratios refer to the total number of patients being treated, including patients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one patient.
(i) Inpatient nonhospital detoxification (residential detoxification).
(A) There shall be one full-time equivalent (FTE) primary care staff person available for every seven patients during primary care hours.
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Observations
Based on a review of administrative staffing documents, the narcotic treatment program failed to ensure that there was one FTE primary care staff person available for every seven patients during primary care hours.
On August 22, 2021, the inpatient nonhospital detoxification census was 26, which required 4 primary care staff persons to be available; however, there were only 3 primary care staff persons available from 12 AM to 6 AM and from 11 PM to 12 AM. Additionally, there were only 2 primary care staff persons available from 8 PM to 10 PM.
On August 23, 2021, the inpatient nonhospital detoxification census was 25 which required 4 primary care staff persons to be available; however, there were only 3 primary care staff persons available from 12 AM to 6 AM.
On August 24, 2021, the inpatient nonhospital detoxification census was 26 which required 4 primary care staff persons to be available; however, there were only 2 primary care staff persons available from 6 PM to 7 PM.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*The narcotic treatment program's administrative, nursing and behavioral staff will monitor client / psychosocial staffing ratio to abide by 715.8(i)(A): Psychosocial Staffing
* The narcotic treatment program's Director will ensure that there are one FTE primary care staff person available for every seven patient during primary care hours.
*Director will reassign FTE primary care staff, if need be to nonhospital detoxification unit to maintain client/psychosocial staffing ratio to abide by 715.8(i)(A): Psychosocial Staffing
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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
Based on a review of patient records, the narcotic treatment program failed to verify the individual's identity, which is to include an emergency contact, prior to the administration of an agent in two of four applicable patient records reviewed.
Patient # 1 was admitted to the inpatient detoxification activity on September 25, 2021 and was still active at the time of the inspection. There was no documentation, in the record, of an emergency contact prior to the administration of an agent.
Patient # 2 was admitted to the inpatient detoxification activity on September 22, 2021 and was still active at the time of the inspection. There was no documentation, in the record, of an emergency contact prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake: Clinical Supervisor will provide in service training with all intake worker(s) the significance of verifying patient identity which includes obtaining emergency contact and any other identifying information from each admission.
Clinical Supervisor will monitor by conducting monthly audits of 10 charts.
Completion Date 10-29
Responsible Party :Clinical Supervisor
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715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document a complete personal history in the patient file in two of four applicable patient records reviewed.
Patient # 1 was admitted to the inpatient detoxification activity on September 25, 2021 and was still active at the time of the inspection. There was no completed personal history documented in the record at the time of the inspection.
Patient # 2 was admitted to the inpatient detoxification activity on September 22, 2021 and was still active at the time of the inspection. There was no completed personal history documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Due to Patient1 & 2 being discharged prior to exit interview , participants personal history's were not completed.
*Clinical Supervisor will provide an in-service training to counseling staff regarding completion of personal history per Policy: 723.03 Bio ?psycho-social
*Clinical Supervisor will conduct random audits of three (3) charts per clinician each month to validate that staff members are correctly following: Policy: 723.03 Bio ?psycho-social
Responsible party- Clinical Supervisor and counselor
Date of compliance 10-19-2021
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document a psychosocial evaluation in the patient record in two of five applicable patient records reviewed.
Patient # 1 was admitted to the inpatient detoxification activity on September 25, 2021 and was still active at the time of the inspection. There was no completed psychosocial evaluation documented in the record at the time of the inspection.
Patient # 2 was admitted to the inpatient detoxification activity on September 22, 2021 and was still active at the time of the inspection. There was no completed psychosocial evaluation documented in the patient at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Due to Patient 1 & 2 being discharged prior to exit interview , participants psychosocial evaluation were not completed as per policy
*Clinical Supervisor will provide a in-service training to counseling staff regarding the proper completion of psychosocial evaluation by October 29, 2021
*Clinical Supervisor will conduct random audits of three(3)charts per clinician each month to validate that staff members are correctly completing psychosocial evaluation by October 29, 2021 and ongoing review of charts.
*Responsible Party: Clinical Supervisor
Completion Date 10/29/2021 |