INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health Systems, Torre De La Raza 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(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
Seven personnel records were reviewed on August 16, 2016.
Personnel record #1 had no documentation of HIV/AIDS or tuberculosis, sexually transmitted disease (TB/STD) training.
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Plan of Correction
Clinical Supervisor will schedule HIV/AIDS or tuberculosis, sexually transmitted disease (TB/STD) training on November 17, 2016.
All new hires will be scheduled to complete HIV and TB/STD training within 60 days of hire. The Administrative assistant for the department will monitor on a monthly basis
Full compliance will be achieved by 10/3016 |
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
Seven personnel records were reviewed on August 16, 2016.
Employee #3, hired on June 16, 2014, had 5 training hours for the training year of January 1, 2015 to December 31, 2015.
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Plan of Correction
Clinical Supervisor will ensure that all required hours will be obtained prior to end of year 2016. Clinical Supervisor will do monthly reviews of credential folders to ensure completion of required hours. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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 residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
A physical plant inspection was conducted on August 17, 2016.
A radiator was leaking in client room 907.
There were no blinds on the window in client room 719.
The kitchen area had a baseboard missing behind the door.
There was a window leaking in the study area.
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Plan of Correction
The facilities manager has been given a list of all citations and is responsible for developing a work list and assigning painters, carpenters and other maintenance personnel to complete the items listed. All repairs will be completed on or before October 15, 2016. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
The physical plant inspection was conducted on August 16, 2016 and August 17, 2016. The facility's trash compactor outside of the kitchen was filled to the point that it was unable to to be closed, thus unable to to prevent the penetration of insects and rodents.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Housekeeping is responsible for insuring that the trash compacted is empty of a timely basis, in order to prevent access by pest and rodents. The trash compacted is scheduled to be emptied on a daily basis, she will monitor the removal of trash and insure that the compactor can be closed beginning immediately. |
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
A physical plant inspection was conducted on August 17, 2016.
The were no slip resistant surfaces in the bathroom showers in rooms 906, 907 and the men's shower room.
The toilet was leaking and the shower had a clogged drain in room 906.
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Plan of Correction
The facilities manager has been given a list of all deficiencies and will complete repairs by October 31, 2016.
The housekeeping director will include inspection of showers in monthly reviews to monitor and replace slip resistant stickers as needed.
The Infectious disease coordinator will conduct monthly inspections and report issues to facilities, housekeeping and program directors.
Full compliance will be obtained by 10/31/16. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Seven personnel records were reviewed on August 16, 2016 for documentation that staff were trained in the use of fire extinguishers upon employment. Documentation in personnel record #1 revealed that employee #1 had not received fire extinguisher training until two months after being hired.
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Plan of Correction
Fire extinguisher training is completed during the first day of new employee orientation for all employees.
The facilities manager will ensure that during the monthly orientations the fire marshall will complete fire extinguisher training to all new hires.
The education department will oversee that all new employees receive the required training through review of sign in sheets.
Full compliance will be reached by November 14, 2016. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Seven personnel records were reviewed on August 16, 2016 for documentation that all personnel on all shifts were trained to perform assigned tasks during emergencies. Documentation in personnel record #1 revealed that employee #1 had not received training until two months after being hired.
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Plan of Correction
Emergency training is provided on the first day of new employee orientation-all new employees will receive training on the first day.
The education department will ensure that during the monthly orientations all new hires will complete training regarding assigned tasks during emergencies from the fire life safety officer.
The education department will oversee that all new employees receive the required training through review of sign in sheets.
Full compliance will be achieved by 11/14/2016 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Seven personnel records were reviewed on August 18, 2016.
Employees #5 and #6 did not have documentation of an annual written individual staff performance evaluation from the previous reviewing year
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Plan of Correction
The Vice President of Residential Services will review and complete all overdue performance evaluation by 10/30/2016. The supervisor will develop a tickler file regarding annual evaluation dates and monitor and complete evaluations on a monthly basis as indicated. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Six client records were reviewed for documentation of informed voluntary consents to release information compliant with 42 CFR and 4 Pa. Code 255.5. Six of six records reviewed contained consents to release information that were not compliant with 42 CFR and/or 4 Pa. Code 255.5, or lacked informed voluntary consents to release information.
42CFR Part 2 Subpart C States:
(a) Required elements. A written consent to a disclosure under these regulations must include:
(1) The specific name or general designation of the program or person permitted to make the disclosure.
(2) The name or title of the individual or the name of the organization to which disclosure is to be made.
(3) The name of the patient.
(4) The purpose of the disclosure.
(5) How much and what kind of information is to be disclosed.
(6) The signature of the patient.
(7) The date on which the consent is signed.
(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third party payer.
(9) The date, event, or condition upon which the consent will expire if not revoked before. This date, event, or condition must insure that the consent will last no longer than reasonably necessary to serve the purpose for which it is given.
42CFR Part 2 Subpart C Prohibition on redisclosure States:
Notice to accompany disclosure. Each disclosure made with the patient's written consent must be accompanied by the following written statement:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
4 Pa. Code States:
(b) Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Client record #1:
Contained a consent to release information to the client's girlfriend dated 7/14/16 that did not list the specific information to be released.
Contained a form (referred to as a "Significant Incident Report") to a third party payer that released information which exceeded what is permissible by 4 Pa. Code 255.5(b). The form contained the full identity of the client and details of the incident. Additionally a note in the file indicated that the information was shared via phone message 8/10/16 and then faxed on 8/10/16. Additionally, there was no statement included with the fax cover sheet or other documents regarding the prohibition of redisclosure per 42CFR Part 2 Subpart C was discussed with the provider and it was clarified that information requested on the form was a clear violation of 42CFR and 255.5(b).
Client record #2:
Contained documentation showing that information was faxed to another service provider dated 8/8/16; however, there was no statement included with the fax cover sheet or other documents regarding the prohibition of redisclosure per 42CFR Part 2 Subpart C documentation showing that information was faxed to probation and parole dated 7/26/16; however, there was no statement included with the fax cover sheet or other documents regarding the prohibition of redisclosure per 42CFR Part 2 Subpart C record #3:
Contained a consent to release information to a health care clinic dated 8/10/16 that did not list the purpose for the released.
Client record #4:
Contained a consent to release information to the client's wife dated 7/15/16 that did not list the information to be released.
Contained a consent to release information to a hospital dated 7/14/16 allowing for the release of admission/discharge status, psychiatric evaluation, resident status, histories, physical exam and medications; however, there was no purpose noted on the consent form.
Contained a consent to release information to probation and parole dated 7/13/16; however, there was no purpose noted on the consent form. Additionally, it was not documented if the client was offered a copy of the consent form or if the client accepted or refused a copy.
Contained documentation noting that information was released to an eye care provider; however, there was no signed consent to release information form allowing for the release of information to the provider in the client record.
Client record #5:
Contained consent to release information forms to two different funding sources, both dated 6/12/16 by the witness; however, the signature of the client was not dated.
Contained a consent to release information to another treatment provider that had an incorrect date of 6/12/26 which was then corrected by the clinician, but, not signed by the client.
Contained a consent to release information form to a CPS(ICM Worker) that did not list the purpose for the disclosure.
Client record #6:
Contained consent to release information forms to two different providers, one dated 8/1/16 and the other dated 8/1/17. In addition to the wrong year noted on the one consent, it was not documented if the client was offered a copy of the consent form or if the client accepted or refused a copy for either provider.
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Plan of Correction
All consent forms will be reviewed and updated by the Sr. Vice President of Behavioral Health Services to ensure conformance with DDAP regulations with specific attention to Client signature and date; in service training will be provided during unit staff meetings and new forms will be issued to all staff on or before September 30, 2016. Full compliance will be obtained by October 1, 2016. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Six client records were reviewed for documentation that clients were informed of their right to inspect their own records, to appeal a decision limiting access to their records to the director, to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and the right to submit rebuttal data or memoranda to their own records.
The facility failed to produce documentation that the clients wee informed of those rights in six of six records reviewed.
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Plan of Correction
The Sr. Vice President will review all Participant handbooks for content related to client rights. The Sr. Vice President will ensure that the handbooks are updated and include an appropriate list of the participants rights and responsibility.
The Sr. Vice President will also review the client rights provided in the Behavioral Access Center to ensure that the forms contain appropriate Participant signatures. The clinical supervisor on the program and the BAC will monitor the process to ensure that Participants are signing that they have been notified of their rights.
Full compliance will be achieved by November 30, 2016 |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
A physical plant inspection was conducted on August 17. 2016. It was observed that the medication cart where a narcotic medication was being stored was not locked.
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Plan of Correction
Nursing Supervisor will ensure that narcotic medications are secured during shifts rounds to unit. Nursing staff will receive training on importance of securing medications. Training will take place on or before 10-21-16. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
A physical plant inspection was conducted on August 17. 2016. It was observed that drugs for external use were stored in the same area as oral drugs.
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Plan of Correction
Nursing Supervisor will ensure that medications are properly stored during shifts rounds to unit. Nursing staff will receive training on proper storage of medications. Training will take place on or before 10-21-16. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Six client records were reviewed for documentation that the client received orientation to the project. Two of six records reviewed lacked documentation the the clients received orientation to the project, specifically, records #4 & 5.
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Plan of Correction
Clinical Supervisor will ensure that orientation is completed with all new admissions and an orientation checklist will be signed by each participant and witnessed by staff. This checklist will them be placed into the participants record. This will be reviewed during the Addiction Recovery Assistant (ARA) staff meeting on 10/20/16. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Six client records were reviewed for documentation of the client's consent to treatment. Two of six records reviewed lacked documentation the the client consented to treatment, specifically, records #4 & 5.
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Plan of Correction
The clinical supervisor on the program and the BAC will monitor the process to ensure that Participants are signing consent to treatment.
Staff will meet with client #4 & #5 to complete consent to treatments and place them in the record.
Full compliance will be achieved by November 15, 2016 |