INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 23, 2010 licensure renewal inspection. The follow-up inspection was conducted on February 3, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 March 7, 2011.
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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 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:
One personnel records were reviewed on February 3, 2011. There was no documentation of HIV/AIDS or TB/STD training in one employee records. Employee #1 was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #1 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 training in the employee's record as of February 3, 2011. Director confirmed that employee #1 did not obtain their HIV/AIDS required training.
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Plan of Correction
All new employee will attend a one week orientation that includes TB/STD, CPR and First Aid training. HIV/AIDS training will be obtained within one year of employment and monitored by their clinical supervisor.
Personnel recorder #1 is schedule for HIV/AIDS (6hrs). Training on May 26, 2011. The Program Director will document attendance and place certificate in her credentinaling file. The secretary for Residential Services will develop a grid to monitor residential staff attendance to all madatory trainings. A quarterly outcome report will be sent to the Clinical Supervisor of each program and the Director of Residential Services. Training requirements that aren't met will be address in supervision with the staff and documented. |
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 August 2010 through January 2011, and interview with facility staff, both occurring on February 3, 2011, 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 August 2010.
The staff person questioned confirmed that there was no documentation of an August 2010 fire drill, nor were there any observation sheets completed for August 2010.
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Plan of Correction
The fire safety officer will start on March 28, 2011. He will be resposible for scheduling all fire drills at GMC Campus. He will be trained by the current safety officer. Fire drill log books will be maintain for each program at the nurse's station. THe results of each drill will be documented by the Mental Health Worker (MHW), Community Recovery Specialist (CRS) and/or Addiction Recovery Assistant (ARA) for their respected floors. The Fire Safety Officer will monitor this process and generate a report of the outcomes on a monthly basis. The results will be distribute to the Program Supervors, Director of Residential Services, Vice President of Behavioral Health Services and the Safety Committee. |
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 August 2010 through January 2011, and interview with facility staff, both occurring on February 3, 2011, the facility failed to maintain a written fire drill record that included 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 September 27, 2010 failed to document the number of persons in the facility at the time of the drill on floors 3, 6, 8 and 9. Also, the facility failed to document the exit route on floors 3, 6, 8, 9 and 10.
The fire drill conducted on October 27, 2010 failed to document the number of persons in the facility at the time of the drill on floors 4, 6, 8 and 11.
The fire drill record of November 30, 2010 failed to document the number of persons in the facility at the time of the drill on floors 1, 3, 4 and 10.
The fire drill conducted on December 27, 2010 no exits used, stated that "no exit was used due to in-climate weather (snow) and rear exits are unsafe and not used during fire drills. The rear exit of the tower building is unsafe to exit due to high weeds, a lock fence and lack of adequate lighting during the night hours." Additionally, the report did not include the number of participants.
The fire drill conducted on January 26, 2011 failed to document the number of persons in the facility at the time of the drill on floors 5, 6, 8 and 9
The staff person questioned confirmed the findings.
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Plan of Correction
The organization is in the process of hiring a competent life safety professional to conduct and assess fire drills as this position is currently vacant leading to some of the problems encountered when conducting and documenting drills. Do to the difficulty of one person documenting 11 floors during unannounced drills. Each floor will have a designated person and backup on all shifts to assist the newly appointed life safety professional in doumenting the required information on the observation sheets.
The maintenance department has cleared the weeds from the rear exit access area and opened up the fence. The exterior of building will be kept free of hazards.
The maintenance department is currently developing plans to increase the lighting in rear of building.
Due to the heavy accumulation of snow and the city declared snow emergency. The residents were told to remain in the lobby and not to exit to the outside.
Do to the difficulty of one person documenting 11 floors during unannounced drills. Each floor will have a designated person and backup on all shifts to assist the newly appointed life safety professional in documenting the required information on the observation sheets. |
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 eight client records reviewed.
The finding includes:
Fifteen records were reviewed on February 3, 2011. Psychosocial evaluations were required in eight records reviewed. The facility director confirmed that this was not documented in the client's records reviewed.
Client records #1, 2, 3, 4, 5, 6 and 8 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Also, client record #7 failed to have documentation of the client's psychosocial evaluation in record reviewed. Per the facility's policy and procedure, psychosocial evaluations will be completed within 30 days of admission. Client record #7 was admitted on December 29, 2010.
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Plan of Correction
The Program Clinical Supervisor will develop a two hour sessions on completing psychosocial evaluations and provide the training to all clinical staff of Torre De La Raza (6 & 10 Tower) by April 30, 2011. The training will include the identification of client's assests, strengths, support system and coping skills. In addition, negative factors that my hampers client's attitude toward treatment and the counselor clinical assessment. The Program Clinical Supervisor will review three current clinical recorders per month of each clinican for the next 90 days during supervision. This process will assure the completion psychosocials within 30 days as well the evaluation of the quality of counselor's assessments. |
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 seven of eight records reviewed.
The findings include:
Fifteen client records were reviewed on February 3, 2011. Support services were required in eight client records. The facility did not document support services in client records # 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. The facility director confirmed that this was not documented in the client's comprehensive treatment plans.
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Plan of Correction
The Program Clinical Supervisor will provide in-service training on treatment plans and the inclusion of support services to all clinical staff of Torre De La Raza (6 & 10 Tower)by April 30, 2011.
The Program Clinical Supervisor will provide ongoing supervision and review with focus on support services and crisis plans for the next 90 days. |
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 three of seven discharge records reviewed.
The findings include:
Fifteen client records were reviewed on February 3, 2011. Aftercare plans were required in three of the seven discharge records reviewed, #8, 11 and 13. Aftercare plan was not required in discharge records #9, 12, 14 and 15 due to client leaving the facility against facility advice. Client records #8, 11 and 13 did not have documentation of the client's goals with time frames. The clinical supervisor confirmed that this was not documented in the client's records reviewed.
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Plan of Correction
The Program Clinical Supervisor will provid in-service training to all clinical staff of TOrre De La Raza (6 & 10 Tower)on development of aftercare plans. The training will include how to identify aftercare needs through psycosocial assessment. Ongoing, development of aftercare plans willcontinue throughout treatment and include goals with time frames. Training will be held by April 30, 2011
Clinical Supervisor will review all aftercare plans for next 90 days and sign all final aftercare plans at time of discharge. |
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 three of seven discharged records reviewed.
The findings include:
Fifteen client records were reviewed on February 3, 2011. Follow-up information was required in three discharge records #9, 10 and 11. Per the facility's policy and procedure, all follow-ups will be done within 30 days of clients discharge if not being referred. Clinical supervisor confirmed that this was not documented in the client's records reviewed.
Client record #9 was admitted on October 22, 2010 and discharged on November 29, 2010. Their follow-up was not documented as of February 3, 2011.
Client record #10 was admitted on November 29, 2010 and discharged on December 6, 2010. Their follow-up was not documented as of February 3, 2011.
Client record #11 was admitted on October 20, 2010 and discharged on December 3, 2010. Their follow-up was not documented as of February 3, 2011.
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Plan of Correction
All follow-up contacts will be completed by all clinical staff of Torrre De La Raza (6 & 10 Tower) within 30 days and documented in follow-up log book. Clinical Supervisor will monitor the follow-up log book on a monthly basis and discuss any concern during monthly supervision. The Program will be in compliance by April 15, 2011. |
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 facility's medication administration records for five clients, the facility failed to maintain accurate records on the individual medications.
The findings include:
Five medication administration records were reviewed on February 3, 2011. All listed inventory records that were inconsistent with the original medication order. The facility director confirmed that there was an issue with the medication record documentation.
Client #1
Drug: Naptoxen 500 mg
Prescribed on 1/27/11
Frequency: One tablet twice a day
Dates not taken: Only took one in the morning on 2/2/11
Client #2
Drug: Cephalexin 500 mg
Prescribed on 1/31/11
Frequency: One capsule every 6 hrs.
Dates not taken: 2/1/11 7 am
2/1/11 3:28 pm
2/1/11 9:55 pm
2/2/11 7 am
2/2/11 3:09 pm
2/2/11 10:04 pm
2/3/11 9 pm
Client #3
Drug: Sertraline (Zoloft) 100 mg
Prescribed on: (no date documented)
Frequency: 2 tablets in the morning
Dates not taken: 1/26/11, 1/27/11, 1/31/11, 2/1/11, 2/2/11 and 2/3/11
Drug: Benztropine Mesylate 1 mg
Prescribed on: (no date documented)
Frequency: one tablet at bedtime
Dates not taken: 1/20/11
Drug: Chlorpromazine HCI 100 mg
Prescribed on: (no date documented)
Frequency: 1 tablet at bedtime
Count: The medication count on 1/21/11 started out at 22 and client took his tablet that day bringing the total count down to 21. On 1/22/11, the beginning count should should have been 21 but what was documented as 20, with no explanation to why the change in count from 1/21/11 at 21 after the client took his dose. On 1/22/11, the count was recorded at 20 before the client actually took his dose. When the client received his medication on 1/22/11 the count was recorded as 19 when it should have been 20. There was no documentation to explain the discrepancy.
Client #4
Drug: Zanca Med 500 mg
Prescribed on: (no date documented)
Frequency: two tablets daily
Dates not taken: 1/21/11, 1/22/11, 1/26/11 only taken once on these dates
Client #5
Drug: Kaletra 200-50 mg
Prescribed on: 1/26/11
Frequency: two tablets twice a day
Dates not taken: 1/29/11 only taken once
Drug: Thiamine HCL 100 mg
Prescribed on: 1/26/11
Frequency: one tablet daily
Dates taken: 1/31/11 taken twice a day instead of two times.
2/2/11 client did not sign
Drug: Aripiprazole 10 mg (abilify)
Prescribed on: 1/26/11
Frequency: one tablet daily
Identified dates when medications were not taken: 2/2/11 not taken, also client and staff initialed before the client actually took the dose, no date, time, amount of dose taken just the staff and client's initial.
Drug: Fluoxetine 10 mg (Prozac)
Prescribed on: 1/26/11
Frequency: one tablet daily
Identified dates when medications were not taken: 2/2/11 not taken, also client initialed before the client actually took the dose, no date, time, amount of dose taken, staff initial, just the client's initials.
Drug: Emtrikenof (Truvada)
Prescribed on: 1/26/11
Frequency: one tablet daily
Identified dates when medications were not taken: 2/2/11 not taken, also client initialed before the client actually took the dose, no date, time, amount of dose taken, staff initial, just the client ' s initial.
Drug: Lipitor 80 mg
Prescribed on: 1/26/11
Frequency: one tablet daily
Identified dates when medications were not taken: 1/27/11, 2/1/11, 2/1/11, also client initialed before the client actually took the dose, no date, time, amount of dose taken, staff initial, just the client's initial.
Drug: Trazodone 50 mg
Prescribed on: 1/26/11
Frequency: one tablet at bedtime
Identified dates when medications were not taken: 2/2/11 not taken, also client initialed before the client actually took the dose, no date, time, amount of dose taken, staff initial, just the client's initial.
Drug: Aspirin EC 81 mg
Prescribed on: (no date documented)
Frequency: one tablet daily
Identified dates when medications were not taken: 1/19/11, 1/20/11, 1/23/11, 1/24/11, 1/25/11, 1/27/11, 1/31/11, (twice on 1/30/11 and 2/2/11)
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Plan of Correction
The program CLinical Supervisor and the Nursing Supervisor will provid in-service training to all Torre De La Raza staff responsible for the self administration of medication. This training will include the proper procedure for counting and recording medication taken and not taken by client by April 15, 2011.
Clinical Supervisor will monitor medication log daily and initial for each shift. THis will be on going process. |