INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2012 to August 15, 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 - Return Program 1 & 2 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications, the facility's staff work schedule from July 16, 2012 to August 15, 2012, the facility failed to ensure that a sufficient number of staff persons trained in first aid and CPR skills were present during all the project's hours of operation.
The findings include:
On August 6, 2012 through August 8, 2012, the facility's personnel records were reviewed. Also, on August 15, 2012, the facility's first aid cards, CPR certifications, and staff work schedules from July 16, 2012 to August 15, 2012 were reviewed.
The facility failed to ensure that at least one person trained in first aid and having current CPR certification was onsite during the following hours on the following dates:
1) from 3:30 P.M. to 11:00 P.M. on 7/16/12, 7/17/12, 7/18/12, 7/19/12, 7/24/12, 7/25/12, 7/26/12, 7/30/12, 7/31/12, 8/1/12, 8/2/12, 8/8/12, 8/9/12, 8/10/12, 8/13/12. 8/14/12 & 8/15/12
2) from 3:00 P.M. to 11:00 P.M. on 7/20/12, 7/23/12, 7/27/12, 8/3/12, 8/6/12, 8/7/12,
3)from 3:30 P.M. on 7/22/12 to 7:00 A.M. on 7/23/12
4) from 7:00 P.M. to 7:00 A.M. on 7/21/12 to 7/22/12, 7/28/12 to 7/29/12, 7/29/12 to 7/30/12, 8/4/12 to 8/5/12, 8/5/12 to 8/6/12, 8/11/12 to 8/12/12, 8/12/12 to 8/13/12
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Plan of Correction
The clinical supervisor will be responsible for reviewing and maintaining records regarding CPR and First Aid on all staff. All staff with currently expired CPR or without First Aid will be mandated to training and will be in compliance on or before 10/15/12. Staff currently without certification will not be allowed to work alone. All new hires will complete First Aid and CPR training within the first 30 days of hire and will not be allowed to work alone. Full compliance will be achieved by 10/15/12. Clinical supervisors will monitor weekly schedules to ensure that at least one staff member with First Aid and CPR are scheduled on each unit. |
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
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:
A physical plant inspection was conducted on August 9, 2012. It was observed during the physical plant inspection from approximately 12:00 P.M. to 12:30 P.M., that there were areas in the employees' and visitors' parking lot that had potholes.
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 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. |
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 physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
A physical plant inspection was conducted on August 14, 2012. It was observed during this inspection at approximately 11:30 A.M., that the unisex staff bathroom in room # 441 located in Returns Program 1 was not ventilated by an exhaust fan or window.
The findings were confirmed during an interview with the safety officer on August 14, 2012 at approximately 11:30 A.M.
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Plan of Correction
Based on the availablity of multiple bathrooms in this facility, this bathroom will be taken offline effective immediatly. Compliance 8/30/12. The Director of Facilities Management will be responsible for ensuring that all bathrooms are vented by exhaust fan or window. Facilites will be inspected monthly by the Director and the Saftey office. |
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 that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment.
The findings include:
The facility's policy titled: "Bio-Psychosocial Assessment Process," states:
"A Integrated Psychosocial Evaluation will be completed by the Behavioral Specialist/Counselor/Counselor Assistant or Social Worker identifying the presenting problems, including an evaluation of the consumers strengths and weaknesses, barriers to treatment, problems which can and cannot be resolved through treatment and that might inhibit treatment, the potential or available supports, the consumers preferred coping mechanisms, the consumers appearance, behavior and reactions during the intake process and conclusions regarding the consumer attitude toward and ability to participate in the treatment process."
On August 14, 2012 to August 15, 2012, five 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 problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment in five of five records reviewed, specifically, client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted on June 25, 2012. The psychosocial evaluation was completed on June 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 # 2 was admitted on June 21, 2012. The psychosocial evaluation was completed on June 21, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems coping mechanisms, negative factors, and attitude toward treatment.
Client # 3 was admitted on July 2, 2012. The psychosocial evaluation was completed on July 3, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems coping mechanisms, negative factors, and attitude toward treatment.
Client # 4 was admitted on July 5, 2012. The psychosocial evaluation was completed on July 6, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems coping mechanisms, negative factors, and attitude toward treatment.
Client # 5 was admitted on June 21, 2012. The psychosocial evaluation was completed on June 22, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems coping mechanisms, negative factors, and attitude toward treatment.
The findings were confirmed during an interview with the facility director on August 14, 2012 at approximately 3:30 P.M.
This is a repeat citation. The facility was cited on August 17, 2011; August 24, 2010; March 16, 2010; September 17, 2009; and August 20, 2008 for noncompliance with this standard.
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Plan of Correction
The clinical supervisor 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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