INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2012 to August 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observations on August 9, 2012, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
The findings include:
The rear visitor's parking lot is shared between several programs contained within the project. A physical plant inspection was conducted on August 9, 2012 following the Administrative Site Visit , from approximately 12:00 PM to 12:30 PM and again upon arriving at the facility on August 23, 2012. The parking lot contained several potholes and loose macadam / stones from the potholes, which presented a hazard to residents, employees, and / or visitors. The findings were confirmed during an interview with the building director on August 9, 2012 at approximately 12:30 P.M.
This is a repeat citation. The facility was cited on December 1, 2011 and August 17, 2011 for noncompliance with this standard.
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Plan of Correction
All of the potholes in the visitor's and employee parking lot have been repaired. The Facilities director will be responsible for insuring that the lot is inspected on a monthly basis and that the lot is maintain in order to avoid and or repair new potholes.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on observations on August 23, 2012, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
A physical plant inspection was conducted on August 23, 2012. On August 23, 2012, 4 staff bathrooms, 4 client bathrooms, and 1 public bathroom were inspected. From approximately 9:30 A.M. to 11:00 A.M., the facility failed to ventilate the following bathrooms by exhaust fan or window.
1)The unisex client bathroom in the cafeteria on the first floor.
2)The unisex client bathroom in the dispensing area on the first floor.
3)Both of the unisex staff bathrooms on the first floor.
4)The unisex client bathroom on the second floor.
The findings were confirmed during an interview with the facility director on August 23, 2012 at approximately 11:00 A.M.
This is a repeat citation. The facility was cited on August 17, 2011 for noncompliance with this standard.
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Plan of Correction
New ventilation blowers were installed in the cited unisex bathrooms.One bathroom has a window which will be use for ventilate.Bathrooms ventilation sytems will be inspected monthly.The blowers were installed September 6,2012.The Director of Facilities Management and Director of Goldman Clinic will ensure that ventiliation blowers are inspected monthly. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observations on August 23, 2012, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
A physical plant inspection was conducted on August 23, 2012. It was observed during the inspection at approximately 10:30 A.M. that the emergency exit on the second floor leading to the green yard was locked.
The findings were confirmed during an interview with the safety officer on August 23, 2012 at approximately 10:30 A.M.
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Plan of Correction
The magnetic lock were removed from the emergency exit on the second floor leading to the yard on August 24 , 2012 . The Life Safety Officer and Director of Goldman Clinic will ensure that stairways , hallways and exit stay unobstructed during the monthly facilities inspection. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare and document alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on August 7, 2012. The records were reviewed from the period covering August 2011 to July 2012. The facility had documented the same exit routes, front exit, in twelve of twelve months reviewed, specifically, August 2011; September 2011; October 2011; November 2011; December 2011; January 2012; February 2012; March 2012; April 2012; May 2012; June 2012; and July 2012.
The findings were confirmed during an interview with the safety officer on August 7, 2012
at approximately 3:00 P.M.
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Plan of Correction
North Philadelphia Health System's Fire marshall will re-oriented the staff to the alternate exit route on August 29,2012. A fire drill will be conducted utilizing the alternate exit in the tower building.The Life Safety Officer and Director of Goldman Clinic will ensure staff utilizes alternate exit routes during scheduled fire drills. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. 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 that included an assessment of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusions/impressions.
The findings include:
The facility's policy titled: "Management Of Treatment Rehab Services" states:
"A Psychosocial Evaluation - Utilizing the completed Psychosocial History, the Counselor completes an evaluation which condenses the information from the Psychosocial History into a more concise, composite picture of the PIR."
On August 21, 2012 to August 23, 2012, fifteen records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included an assessment of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusion/impressions in fifteen of fifteen records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15.
Client # 1 was admitted on March 23, 2012. The psychosocial evaluation was completed March 26, 2012. However, the psychosocial evaluation did not include an evaluation of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 2 was admitted on May 2, 2012. The psychosocial evaluation was completed May 3, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 3 was admitted on March 28, 2012. The psychosocial evaluation was completed April 20, 2012. However, the psychosocial evaluation did not include an evaluation of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions/impressions.
Client # 4 was admitted on February 21, 2012. The psychosocial evaluation was completed March 8, 2012. However, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 5 was admitted on March 9, 2012. The psychosocial evaluation was completed April 4, 2012. However, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, and attitude toward treatment.
Client # 6 was admitted on April 24, 2012. The psychosocial evaluation was completed April 27, 2012. However, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 7 was admitted on March 16, 2012. The psychosocial evaluation was completed March 22, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, coping mechanisms, negative factors, and attitude toward treatment.
Client # 8 was admitted on April 27, 2012. The psychosocial evaluation was completed May 24, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, coping mechanisms, negative factors, and attitude toward treatment.
Client # 9 was admitted on March 15, 2012. The psychosocial evaluation was completed April 12, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 10 was admitted on June 21, 2012. The psychosocial evaluation was completed July 23, 2012. However, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 10 was admitted on June 21, 2012. The psychosocial evaluation was completed July 23, 2012. However, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 11 was admitted on June 15, 2012. The psychosocial evaluation was completed July 23, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 12 was admitted on March 28, 2012 and discharged on May 23, 2012. The psychosocial evaluation was completed April 17, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 13 was admitted on January 17, 2012 and discharged on July 13, 2012. The psychosocial evaluation was completed February 10, 2012. However, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 14 was admitted on February 6, 2012 and discharged on June 5, 2012. The psychosocial evaluation was completed March 16, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 15 was admitted on April 20, 2012 and discharged on July 20, 2012. The psychosocial evaluation was completed May 25, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
The findings were confirmed during an interview with the clinical supervisors on August 23, 2012 at approximately 2:00 P.M.
This is a repeat citation. The facility was cited on August 17, 2011; August 17, 2010; March 15, 2010; September 16, 2009; August 15, 2008; October 26, 2007.
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Plan of Correction
The clinical supervisors will provide and in-service training session utilizing an evaluation identified during the review as meeting state guidelines with all of the clinical staff. The supervisor review and sign all evaluation to ensure that they meet policy guidelines. The clinical supervisor will focus supervision for the next 60 days on this area. Full compliance will be achieved by 10/30/12. The clinical supervisor will monitor for ongoing compliance on a monthly basis.
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711.92(c)(3) LICENSURE Support Service
711.92. 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 a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan.
The findings include:
The facility's policy titled: "Management Of Treatment Rehab Services," states:
"A Comprehensive Treatment Plan - The Counselor develops this plan based on the chart documentation, including the Psychosocial History and other evaluations. This plan should identify critical PIR problems and strategies for their resolution."
On August 21, 2012 to August 23, 2012, fifteen client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in nine of fifteen records reviewed, specifically, client records # 3, 4, 5, 6, 10, 11, 12, 14, and 15.
Client # 3 was admitted March 28, 2012. The individual treatment and rehabilitation plan was completed on April 13, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 4 was admitted February 21, 2012. The individual treatment and rehabilitation plan was completed on March 29, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 5 was admitted March 9, 2012. The individual treatment and rehabilitation plan was completed on April 4, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 6 was admitted April 24, 2012. The individual treatment and rehabilitation plan was completed on April 27, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 10 was admitted June 21, 2012. The individual treatment and rehabilitation plan was completed on July 23, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 11 was admitted June 15, 2012. The individual treatment and rehabilitation plan was completed on July 13, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 12 was admitted March 28, 2012. The individual treatment and rehabilitation plan was completed on April 27, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 14 was admitted February 6, 2012. The individual treatment and rehabilitation plan was completed on March 7, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
Client # 15 was admitted April 26, 2012. The individual treatment and rehabilitation plan was completed on May 25, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 23, 2012.
The findings were confirmed during an interview with the clinical supervisors on August 23, 2012 at approximately 2:00 P.M.
This is a repeat citation. The facility was cited on August 17, 2011 for noncompliance with this standard.
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Plan of Correction
Policy 711.91(b)(2)was revised 9/20/2012 to address and reinforce the importance of documenting support services in individual treatment plans. The Project Director has approved the policy revision.
In-service training regardly inculision of support services will be provided to all of the counselors by the clinical supervisors by Oct 15, 2012. Clinical supervisiors will monitor the treatment plans during weekly supervison sessions. Full compliance will be reached by October 31, 2012. Ongoing compliance will be monitor on a monthly basis. |