INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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.
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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, staffing requirements facility summary report 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:
On August 8, 2011 through August 9, 2011, eight personnel records were reviewed for documentation of the required HIV/AIDS and TB/STD trainings. There was no documentation of HIV/AIDS or TB/STD training in two of eight employee records reviewed, a counselor and a support staff.
Employee #4, a counselor, was hired March 30, 2009 and was required to have HIV/AIDS & TB/STD training by March 30, 2010. There was no documentation of HIV/AIDS training in the employee's record as of August 9, 2011.
Employee #8, a support staff member, was hired April 15, 2008 and was required to have HIV/AIDS & TB/STD training by April 15, 2010. There was no documentation of HIV/AIDS training in the employee's record as of August 9, 2011.
An interview with facility staff on August 19, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the August 23, 2010 licensing inspection.
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Plan of Correction
Begining October 1, 2011 the New employee orientation schedule will include a six hour DOH curriculum approved HIV/AIDS session so that all new Behavorial Staff will receive mandatory tranining prior to assignment to the program. The Education Department and the Infectious Disease department will be resposible for developming and implementing the training. On or before December 31, all staff currently non-compliant will recieve mandatory training. The clinical supervisors will be responsible for monitoring credential files to ensure that staff have recieved training. Programs will be fully compliant by December 31, 2011. |
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 a physical plant inspection, the facility failed to keep the grounds of the facility safe and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
An inspection of the facility ' s physical plant was conducted on August 18, 2011 between approximately 8:30 AM and 11:00 AM. The employee and visitors' parking lot was unsafe and in poor condition at the time of inspection.
The parking lot was unsafe due to the asphalt being uneven and having many potholes. Because of the size and number of potholes, it is hazardous to walk in the parking lot, and it is also impossible for drivers to avoid the potholes when driving in the parking lot.
The findings were confirmed by the facility director on August 18, 2011.
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Plan of Correction
NPHS has obtained bids on the repair of the parking lot. The repair will be completed on or before 10/31/11. The CEO is reponsible for authorizing and ensuring repair.
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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 the review of client records and facility policy and procedures, the facility failed to document a psychosocial evaluation in accordance with facility policy.
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 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 consumers attitude toward and ability to participate in the treatment process."
On August 16, 2011, six client records requiring psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation as per facility policy in six of six records reviewed, specifically, records # 1, 2, 3, 4, 7 and 8.
Client # 1 was admitted on 7/6/11. The psychosocial evaluation in client record # 1 dated 6/19/11 did not include the client's assets and strengths, support systems, coping mechanisms, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 2 was admitted on 6/29/11. The psychosocial evaluation in client record # 2 was not dated, and it did not include the client's assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 3 was admitted on 1/28/11. The psychosocial evaluation in client record # 3 dated 1/28/11 did not include the client's problems, assets and strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 4 was admitted on 1/18/11. The psychosocial evaluation in client record # 4 dated 2/2/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
Client # 7 was admitted on 7/13/11. The psychosocial evaluation in client record # 7 dated 7/18/11 did not include the client's assets and strengths, support systems, and coping mechanisms.
Client # 8 was admitted on 6/28/11. The psychosocial evaluation in client record # 8 dated 7/1/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors, conclusions regarding the client's appearance and behavior during the initial interview, and conclusions regarding the client's attitude toward and ability to participate in the treatment process.
The findings were confirmed by the facility director on August 16, 2011.
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Plan of Correction
Small group instruction in evaluation/case formulation will be conducted by the education department in cooridnation with the Chief of psychology. All clinical staff will participate in the training. All clinical staff will complete retraining by October 31, 2011. Supervision sessions conducted by program managers over the next 90 days will focus on evaulations. |
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 treatment plans to include proposed types of supportive services.
The findings include:
On August 16, 2011, six client records requiring treatment plans in were reviewed. The facility did not document treatment plans to include a proposed type of support service in four of six client records reviewed, specifically, # 2, 3, 4 and 7.
Client # 2 was admitted on 6/29/11. The treatment plan in client record # 2 dated 7/7/11 did not include a proposed type of support service.
Client # 3 was admitted on 1/28/11. The treatment plan in client record # 3 dated 2/4/11 did not include a proposed type of support service.
Client # 4 was admitted on 1/18/11. The treatment plan in client record # 4 dated 2/4/11 did not include a proposed type of support service.
Client # 7 was admitted on 7/13/11. The treatment plan in client record # 7 dated 7/26/11 did not include a proposed type of support service.
The findings were confirmed by the facility director on August 16, 2011.
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Plan of Correction
Small group instruction in treatment planning including the documentation of support services. All clinical staff will participate in the training. All clinical staff will complete retraining by October 31, 2011. Supervision sessions conducted by program managers over the next 90 days will focus on this issue. |
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 to include goals with time frames as per facility policy.
The findings include:
On August 16, 2011, four client records requiring aftercare plans were reviewed. The facility did not document aftercare plans to include immediate and long-term goals, as per facility policy, in four of four client records reviewed, specifically, # 3, 4, 5 and 6.
The facility's policy titled "Discharge Procedures Aftercare Planning" states:
"It is the policy of NPHS/Residential Services to complete a Patient Aftercare and Discharge Instructions Plan on all consumers ....
Immediate and long-term goals are included in Aftercare planning."
Client # 3 was admitted on 1/28/11. The aftercare plan in client record # 3 dated 3/28/11 did not include future goals with time frames.
Client # 4 was admitted on 1/18/11. The aftercare plan in client record # 4 dated 3/24/11 did not include future goals with time frames.
Client # 5 was admitted on 3/15/11. The aftercare plan in client record # 5 dated 5/6/11 did not include future goals with time frames.
Client # 6 was admitted on 2/18/11. The aftercare plan in client record # 6 dated 4/18/11 did not include future goals with time frames.
The findings were confirmed by the facility director on August 16, 2011.
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Plan of Correction
The VP of Behavorial Health Services has revised the the policy and procedure to read: It is the policy of NPHS Residential Services to complete discharge Instructions on all consumers who complete the program. After care plans will only be completed on consumers who are leaving the drug and alcohol treatment system. After care Plans will not be completed on consumers who AFA, AWOL or those being referred to another level of care within the drug and alcohol system. When completed aftercare plans will include short and long term goals with time frames. The policy will be reviewed and implemented by September 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 facilities medication administration records for eight clients, the facility failed to maintain accurate records on the individual medications.
The findings include:
On August 18, 2011, eight medication administration records were reviewed. Eight of those listed inventory records that were inconsistent.
Client #9
Drug: Aripiprozole 10 mg
Prescribed on 8/12/11
Frequency: May take at night 1 tab once a day
Dates not taken: Client refused on 8/13/11, 8/14/11 and 8/15/11 and there was no documentation in record why they client refused the medication. Client did not take on 8/16/11 and there was no documentation if the client refused or if they just missed taking their medication.
Client #10
Drug: Multivitamin Tab
Prescribed on 7/11/11
Frequency: Take 1 tablet daily
Dates not taken: 7/15/11
7/16/11
7/17/11
Drug: NicoDerm
Prescribed on 8/8/11
Frequency: 1 patch daily
Dates not taken: 8/15/11
Drug: Milk of Magn Sus 355 ml
Prescribed on 7/14/11
Frequency: Take orally 2 tbls (30ml) at bedtime
Dates not taken: There was not documentation why client stopped taking this medication. The last time the client took this medication was on 7/15/11. Doesn't state that this medication was discontinued.
Client #11
Drug: Metronidazo/500 mg (flagyl)
Prescribed on: 8/14/11
Frequency: Take 1 tablet by mouth 3 x a day
Dates not taken: Client only took once on 8/16/11 and does not state why the client did not take the other two for that day. Client only took twice on 8/17/11 and does not state why the client did not take the other one that day.
Client #12
Drug: Trazodone 100 mg (Desyrel)
Prescribed on 8/4/11
Frequency: One tablet @ bedtime
Dates not taken: The client did not take on 8/8/11 and the client took it twice on 8/9/11.
Drug: Ibuprofen 800 mg (Motrin)
Prescribed on 7/21/11
Frequency: One tablet every 8 hrs.
Dates not taken: Client not taking medication every 8 hrs as prescribed. 7/22/11 (10:30 am), 7/23/11 (8 PM), 7/24/11 (8 am), 7/25/11 (9 PM), 7/25/11 (9 PM), 7/29/11 (3 PM), 7/30/11 (9 am), 8/1/11 9 am, 8/1/11 (4 PM), 8/2/11 (9 am), 8/3/11 (5 PM), 8/4/11 (9 am), 8/9/11 (9 am), 8/10/11 ( 9 am), 8/11/11 (9 am), 8/12/11 (9 am), 8/13/11 (9 am), 8/14/11 (9 am)
Client #13
Drug: Multivitamin
Prescribed on 8/11/11
Frequency: One tablet daily
Dates not taken: The date documented on the client medication log states that the client took their medication on 8/31/11 at 7 PM.
Drug: Epzicom Tab 600-300 mg
Prescribed on 8/11/11
Frequency: One tablet daily
Dates not taken: The date documented on the client medication log states that the client took their medication on 8/31/11 at 7 PM.
Drug: Norvir
Prescribed on 8/11/11
Frequency: One tablet daily
Dates not taken: The date documented on the client medication log states that the client took their medication on 8/31/11 at 7 PM.
Client #14
Drug: Ibuprofen 800 mg tab (Motrin)
Prescribed on 7/28/11
Frequency: every 8 hours
Dates not taken: Client not taking medication every 8 hrs as prescribed. 8/10/11 (9 PM), 8/11/11 (9 am), 8/11/11 (9 PM), 8/12/11 (9 am), 8/12/11 (4:30 PM), 8/13/11 (4 am), 8/13/11 (2 PM), 8/13/11 (5 PM), 8/14/11 (9 am), 8/15/11 (9:15 PM), 8/16/11 (6:15 am ), 8/16/11 ( 3 PM), 8/17/11 (9 am), 8/17/11 (5 PM) and 8/18/11 (9 am).
Drug: Trazodone 50 mg tab
Prescribed on 7/21/11
Frequency: One tablet @ bedtime
Dates not taken: Client did not take on 8/14/11, 8/15/11, 8/16/11 and 8/17/11 with no documentation why.
Drug: Geodon 60 mg
Prescribed on 8/4/11
Frequency: one tablet twice a day
Dates not taken: client only took once on 8/14/11 and refused on 8/15/11, 8/16/11 and 8/17/11 with no documentation of why. On 8/17/11 the count started at 38 pills and one pill was taken on that date bringing the count to 37 then on 8/18/11 the count started at 36 and one pill was taken on that day bringing the count to 35. No documentation on 8/17/11 or 8/18/11 showing another dose was given to the client making the count off by one.
Drug: Combivir
Prescribed on 7/21/11
Frequency: Not documented
Dates not taken: could not determine if client was supposed to take it once a day or twice a day.
Drug: Kaletra 200-50M
Prescribed on 7/21/11
Frequency: 2 tablets twice a day with food
Dates not taken: One 8/12/11 the count started at 35 and client took two tablets brining the count to 33. Then on 8/13/11 the count again started at 35 and client took two tablets brining the count to 33. Count is not wrong due to this mix-up. The medication for this client is to be taken at 9 am and 9 PM and on 8/18/11 there was no documentation that client took their medication on 8/18/11 in the morning.
Drug: Ibuprofen 800 mg (Motrin)
Prescribed on 8/14/11
Frequency: Not documented
Dates not taken: could not determine if client was supposed to take it once a day or twice a day. Then the last time the client took this medication was on 8/15/11 none taken on 8/16/11, 8/17/11 or 8/18/11.
Client #15
Drug: Benztropine 1 mg (Cogentin)
Prescribed on 7/21/11
Frequency: Not documented
Dates not taken: could not determine if client was supposed to take it once a day or twice a day. On 8/1/11 the start count was 27 pills and client took one brining the count to 26. Then on 8/3/11 the start count was 25 pills and the client took one brining the count to 24. The count is off by one with no documentation of why. Client did not take their medication on 7/26/11, 7/28/11, 7/29/11, 7/30/11, 8/2/11, 8/4/11, 8/5/11, 8/6/11, 8/7/11 and 8/8/11.
Drug: Haloperidol 5 mg tab
Prescribed on 7/21/11
Frequency: Not documented
Dates not taken: could not determine if client was supposed to take it once a day or twice a day.
Drug: Multivitamin
Prescribed on 7/21/11
Frequency: One tablet daily
Dates not taken: Client did not take on 8/5/11, 8/6/11, 8/7/11, 8/8/11, 8/9/11, 8/10/11, 8/12/11, 8/13/11, 8/14/11, 8/15/11, 8/16/11, 8/17/11 and 8/18/11.
Client #16
Drug: Seroquel 200 mg
Prescribed on 8/10/11
Frequency: 1 tablet @ bedtime
Dates not taken: Count ended on 8/13/11 with one pill left to take 8/14/11 was not documented showing the client taking the last pill.
Drug: Gabapentin 600 mg tab
Prescribed on 8/11/11
Frequency: 1 tablet two times a day
Dates not taken: Only took it once on 8/14/11.
Drug: Losartan Pot 50 mg tab (Cozaar)
Prescribed on 8/12/11
Frequency: take 1 tablet daily
Dates not taken: Count on 8/16/11 at 9 PM started with 27 pills and the client took one and the count was 26 pills. On 8/17/11 the count started off at 25 pills and the client took on and the count was 24 pills. The count was off by one based on what is documented in the medication log. Also 8/6/11 and 8/15/11 not documented and the client took pills at two different times on 8/16/11.
Drug: Citalopram 20 mg tab (Celexa)
Prescribed on 8/10/11
Frequency: 1 tablet daily
Dates not taken: Client took times on 8/14/11 one at 9 am and the other at 10:15 PM. Client also did not take on 8/15/11.
Drug: Seroquel 100 mg
Prescribed on 8/10/11
Frequency: 1 tablet daily
Dates not taken: On 8/14/11 the count started at 1 pill left to take for this med but then the next day 8/15/11 again the count started with one pill and nothing left to take. Not sure if this was an error on the staff who documented that there were no pills left on 8/14/11 or the count was just wrong.
Drug: Oyster Cal 500 mg tab
Prescribed on 8/11/11
Frequency: 1 tablet 2x a day
Dates not taken: Only took once on 8/14/11
The facility staff confirmed that there was an issue with the medication record documentation.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the February 3, 2011 follow-up inspection and the August 23, 2010 licensing inspection.
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Plan of Correction
Effective October 3, 2011 all medication will be administered by the nursing department. NPHS will discontinue the policy of self administration under the supervision of staff which has led to the inconsitency in record keeping. The VP of nursing will be responsible for rewriting the dispensing policy and for inservicing the the nursing staff on the new procedures. The nurse manager will monitor implementation of the new procedure.
Full compliance will be achieved by 10/31/2011. |