INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System - Torre De La Raza 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 and a plan of correction is due on September 24, 2010.
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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 personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Six personnel records were reviewed on August 11, 2010 through August 16, 2010 and the staffing requirements facility summary report was reviewed on August 11, 2010 through August 12, 2010. There was no documentation of HIV/AIDS or TB/STD training in one employee records. Of the six, five was to have HIV/AIDS and TB/STD training within the first year of employment and the rest was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #6 was hired January 14, 2008 and was required to have HIV/AIDS & TB/STD training by January 14, 2010. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of August 16, 2010.
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Plan of Correction
The New Employee orientation will be modified to include HIV/AIDS and First Aid training along with the TB/STD and CPR training in order to insure that all new hires obtain the DOH mandatory training requirements. The infection disease department will be responsible for providing HIV/AIDS and the education department will be responsible for providing First Aid. The modification will take place by November 2010.
By December 31, 2010 all current staff who is not compliant for training will receive the DOH mandatory training.
The Program Directors and the AVP or nursing will be responsible for ensuring that all staff has obtained required training.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a tour of the facility ' s physical plant and an interview with the facility director, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The facility was required to ventilate all toilets and wash rooms by exhaust fan or window.
The facility did not ventilate the staff toilet on the 6th floor of the Tower Building.
The facility director confirmed that ventilation was not provided in the staff toilet.
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Plan of Correction
All the vent motors were replaced during the survey. The Director of Plant Facilities will place the monitoring of vent motors as a part of the monthly preventative maintenance rounds. Fully compliance August 26, 2010.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
The facility fire drill record did not include any record of a fire drill for June 2010.
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The staff person questioned confirmed that there was no documentation of a June 2010 Fire drills, nor were there any observation sheets completed for December 31, 2009.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building.
The fire drill conducted on November 27, 2009 failed to document the exit route used.
The fire drill conducted on January 18, 2010 did not identify the exit route.
The fire drill record of February 25, 2010 only contained documentation for the ninth floor of the Tower building.
The fire drill conducted on April 6, 2010 did not include the number of participants.
The fire drill conducted on May 26, 2010 had a note that the indicated no evacuation due to early morning.
The staff person questioned confirmed the findings.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation to include the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions in seven of seven client records reviewed.
The finding includes:
Seven records were reviewed on August 23, 2010. Psychosocial evaluations were required in Seven records reviewed.
Client records #1, 4, 7 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client records #2 failed to document the client's assets/strengths, support systems, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impression.
Client record #3, 6 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions.
Also, client record #5 failed to have documentation of the clients psychosocial evaluation in record reviewed. Per the facility's policy and procedure psychosocial evaluations will be completed within 30 days of admission. Client record #6 was admitted on 6/18/10 and discharged on 8/17/10.
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Plan of Correction
The Director of Outpatient Psychiatry will develop a three hour training sessions on completing psychosocial evaluations and will provide the training to all clinical staff by November 30, 2010.
A psychologist from the Outpatient Department will conduct random reviews of evaluations and meet with clinical staff to review case formulations/evaluations for the next 90 days.
The clinical supervisors will review three cases per month of each clinician for the next 90 days, focusing on psychosocial evaluations.
Ongoing monitoring will be conducted by the clinical supervisors and full compliance will occur by December 31, 2010.
The training department will provide in service training on treatment plans and the inclusion of support service in planning by October 15, 2010. The clinical supervisor will provide ongoing supervision and review with focus review on support services for the next ninety days. The program will be fully compliant by November 30, 2010. |
711.52(c)(3) LICENSURE Support Service
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services in four of seven records reviewed.
The findings include:
Seven client records were reviewed on August 23, 2010. Support services were required in six client records. The facility did not document support services in client records # 3, 4, 5 and 7.
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Plan of Correction
The training department will provide in service training on treatment plans and the inclusion of support service in planning by October 15, 2010. The clinical supervisor will provide ongoing supervision and review with focus review on support services for the next ninety days. The program will be fully compliant by November 30, 2010. |
711.53(a)(6) LICENSURE Aftercare Plan
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans addressing the client ' s goals with time frames in four of three discharge records reviewed.
The findings include:
Seven client records were reviewed on August 23, 2010. Aftercare plans were required in three of four discharge records reviewed, #5, 6 and 7. Aftercare plan was not required in discharge record #4 due to client leaving the facility against facility advice. Client records #5, 6 and 7 did not have documentation of the client ' s goals with time frames.
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Plan of Correction
The clinical supervisor will provide a review of Aftercare planning during the next staff meeting and will review all aftercare plans for the next sixty days. The program will be in compliance by October 31, 2010. |
711.53(a)(7) LICENSURE Follow-up Information
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document timely follow-up information in one of four discharged records reviewed.
The findings include:
Seven client records were reviewed on August 23, 2010. Follow-up information was required in two discharge records #6 and 7. Per the facilities policy and procedure all follow-ups will be done within 30 days of clients discharge if not being referred.
Client record #6 was admitted on 3/19/10 and discharged on 6/2/10 and their follow-up was not documented as of August 23, 2010.
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Plan of Correction
All outstanding follow-up contacts will be completed immediately. The overnight Addiction Recovery Assistant or Mental Health Worker will review the follow-up book on a daily basis and complete follow-ups as required beginning immediately. The clinical supervisor will monitor the log book on a monthly basis. The program will be in compliance by October 15, 2010. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to document consent to release forms for letters, faxes and calls made pertaining to the client in three of seven client records reviewed.
The findings include:
Seven client records were reviewed on August 23, 2010. Consent to release forms were required in Seven client records reviewed.
Client record #1 had a letter dated 6/29/10 addressed "to who it may concern" with no identifying agency or person. The letter had information of the clients admit date and expected release date. Could not verify if the facility had a consent to release form. Progress notes dated 8/5/10 documented calls made to several recovery houses and another treatment agency and there were no documentation of consent in record reviewed. Progress note dated 7/16/10 a call was made to a man and agency but did not see a consent in record reviewed for either person or agency. Progress note dated 7/9/10 documented that the therapist faxed information to the court system stating client was in rehab, but consent was not documented in client record.
Client record #2 fax sent out on 8/11/10 to a person which gave out the clients medical information. Did not see a consent to release for this person.
Client record #6 Letters sent out "to who it may concern" dated 4/5/10 and 3/22/10 pertaining to client. Had not identifying information to see if a consent was in record. Fax went out on 4/15/10 to a agency but did not see a consent in client's record for this agency. Discharge Summary sent to P.O. dated 6/4/10 did not see a consent to release for the clients P.O. and if they had a consent it would have exceeded 255.5.
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Plan of Correction
The clinical supervisor will review the records and obtain appropriate release forms. The clinical supervisor will provide an in service regarding release on information to clinical staff by September 24, 2010. The clinical supervisor will conduct a focus monitor of release of information for the next ninety days and will continue ongoing monitoring thereafter. |
711.58(a)(4) LICENSURE Control/accountability of Drugs
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on the review of the facilities medication administration records for Thirteen clients, the facility failed to maintain accurate records on the individual medications.
The findings include:
Thirteen medication administration records were reviewed on August 25, 2010. Eight of those listed inventory records that were inconsistent.
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Plan of Correction
In service training will be provided to all staff responsible for the self administration of medication by the education department by October 15, 2010.
Revision of the self-administration policy will be completed by September 30, 2010 by the Vice President of Behavioral Health to clarify the responsibility of counting medication as a staff issue. Staff will receive re-education regarding policy by October 15, 2010.
Clinical supervisor will conduct a daily focused monitor of the medication log for the next 45 days to insure compliance. Programs will be fully compliant by October 30, 2010.
On going monitoring will be conducted by the clinical supervisors.
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