INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12, 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, Return 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:
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The physical plant inspection was conducted on August 17, 2016.
Observations included:
Some walls of the third floor were buckling and baseboards warped in the hallway.
Tape was covering holes in the wall in one of the client lounges.
Room 319 had a chipped floor tile.
Room 324 was missing slats in the HVAC vent.
Room 327, which is used as a counselor office, had a peeling baseboard.
An outlet cover was not properly affixed to the wall and also exposed a small florescent light in room 333.
The front of the HVAC unit in room 339 was not properly attached and was propped against the machine.
The following rooms were missing plate covers for abandoned medical gases: 332, 334, 336, 341, and 342.
Chipped paint and/or marked walls were found in the following bedrooms: 317, 318, 319, 324, 325, and 336.
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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. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
The physical plant inspection was conducted on August 17, 2016. The facility failed to maintain furnishings in a state of good repair in one of the client lounges. Cushions were ripped and torn on multiple couches in the lounge.
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Plan of Correction
The Director of Housekeeping will remove all replace all compromised furniture. The clinical supervisor will monitor the condition of furniture and report problems to the Program Director and the Director of Housekeeping on a monthly basis. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The physical plant inspection was conducted on August 17, 2016.
Observations included:
Chipped paint and/or pealing wallpaper was found in the following bathrooms: 317, 324, 325, 331, 332, 334, 336, and 341.
There were missing fluorescent light fixture covers in the following restrooms: 332, 334, 339, and in the lounge restroom.
Room 325 had a loose splatter guard at the base of the wall and it did not appear to be attached to the wall.
Rooms 324 and 333 had mold or mildew in the shower.
The handicapped restroom had a chipped tile around a drain and peeling wallpaper.
The toilet in room 322 was not flushing and the sink was slow to drain.
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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. |
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
Six personnel records were reviewed on August 16, 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 clinical supervisor 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
Ten client records were reviewed on August 12, 2016. The facility failed to obtain an informed and voluntary consent in nine of ten client records reviewed. Additionally the facility exceeded 4 PA. Code in client records #3 and #9.
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, 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) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client #1 - Consent to a probation officer was missing a date or condition upon which the consent will expire.
Client #2- Consent to the funding source had a dated signature of the witness as July 6, 2016 and a dated signature of the client as July 7, 2016.
Client #3- Consents to two funding sources were missing dated signatures of the client. Consent to a probation officer exceeded 4 PA. Code by allowing the following information to be released: psychiatric evaluation, psychosocial history, copies of progress notes, history and physical examination and results of urine drug screen (UDS).
Client #4- Consent to a family member did not identify specific information that can be disclosed and the purpose of the disclosure. Consent to a treatment provider did not specify what information can be disclosed and was missing a date or condition upon which the consent will expire. Additionally, consents to two funding sources were missing dated signatures of the client.
Client #5- Consent to a physician did not specify the purpose of the disclosure. Consents to two funding sources were missing dated signatures of the client. Additionally, the facility released patient identifying information to a pharmacy on July 25, 2016. The facility failed to obtain an informed and voluntary consent to this pharmacy prior to the release.
Client #7- Consents to two funding sources were missing dated signatures of the client.
Client #8- Consents to two funding sources were missing dated signatures of the client.
Client #9- Consents to two funding sources were missing dated signatures of the client. The facility released patient identifying information to a family member on February 17, 2016. The facility failed to obtain an informed and voluntary consent to this family member prior to disclosure. Consents to three probation officers exceeded 4 PA. Code by allowing the following information to be released: psychiatric evaluation, psychosocial history, history and physical examination and results of urine drug screen (UDS).
Client #10- Consent to an outpatient psychiatric service did not specify the name of the agency and the purpose of the disclosure. Consent to a treatment provider did not specify the purpose of the disclosure and what information can be disclosed. Additionally, consents to two funding sources were missing dated signatures of the client.
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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.
New and appropriately executed consent forms will be obtain on all participants still active in the program by October 25, 2016
Full compliance will be obtained by October 31, 2016.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Ten client records were reviewed on August 12, 2016. The facility failed to document that the client was offered a copy of their consents in client record #10.
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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.
New and appropriately executed release forms will be obtained on all active participants in the program by October 25. 2016
Full compliance will be obtained by October 31, 2016.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Ten client records were reviewed on August 12, 2016 for documentation that the clients had been informed of their rights. The facility failed to document written acknowledgement by clients that they had been notified of the client rights.
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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 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 October 15, 2016 |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Ten client records were reviewed on August 12, 2016 for treatment and rehabilitation plans. The facility failed to document treatment and rehabilitation plans that included the type and frequency of services and or support services 10 of 10 records reviewed.
Clients #1, #8, #9, #10- the individual treatment and rehabilitation plan did not include written documentation of type and frequency of treatment and rehabilitation services.
Clients #2, #3, #4, #5, #6, #7- the individual treatment and rehabilitation plan did not include written documentation of type and frequency of treatment and rehabilitation services and proposed support services.
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Plan of Correction
6. Support services
By 10/31/16, The Clinical Supervisor of the IOP program will train all clinical staff on how to add a list of proposed support services when updating treatment plans.
By 10/31/16, The Clinical Supervisor of the IOP will train all of the clinical staff on how to include in the treatment plans, the type and frequency of treatment and rehabilitation services.
Beginning 11/1/16, the Clinical supervisor will inspect participants' electronic charts on a weekly basis to ensure:
1. That treatment plans are completed on time and are located in the right electronic file.
2. that treatment plans include propose support services list
3. That treatment plans include type and frequency of treatment and rehabilitation services.
All Active client charts will be reviewed and treatment plans updated to include support services, as well as type and frequency of services.
Full compliance will be achieved by 11/17/16 |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Ten client records were reviewed on August 12, 2016. Ten out of ten records reviewed failed to include documentation that work done by the client at the project is an integral part of his treatment and rehabilitation plan. The Return 1 &2 program handbook identifies that chores and work assignments are part of the client's individual responsibilities. A chore chart was also posted in a lounge on the unit.
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Plan of Correction
All active charts will be reviewed and updated to include "work therapy" as part of the treatment plan by 11/15/16.
Beginning 11/1/16, the Clinical supervisor will inspect participants' electronic chart to ensure:
1. That treatment plans are completed on time and are located in the right electronic file.
2. that treatment plans include work therapy as an integral part of the treatment where applicable.
Full compliance will be achieved by 11/15/16
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