INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 27, 2021 through May 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, North Philadelphia Health System DD/FIR 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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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of fourteen client records reviewed.
Client # 7 was admitted on January 29, 2021 and was discharged on February 3, 2021. The release of information form to a parole officer was signed and dated by the client on January 29, 2021; however, the form failed to document the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical supervisor will review Client# 7,with assigned counselor(s)to discuss importance of documenting the purpose of the of disclosure on consents forms by June 18,2021
*Clinical Supervisor will provide a in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents and purpose of the disclosure by June 18, 2021
*Clinical Supervisor will conduct random audits of three(3)charts per clinician each month to validate that staff members are correctly completing consent forms by June 18, 2021 and ongoing review of charts.
*Clinical Supervisor will document outcome of consent chart audit in Performance Improvement report quarterly by June 18, 2021.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's October 2019 through April 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on April 11, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Incident reports will be submitted for all incidents noted in the citation by the administrative assistant of the Program by June 4, 2021.
Responsible party-Administrative Assistant
Date of compliance 6-4-2021
Beginning June 1, 2021 Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning June 1, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: June 4, 2021
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data, prior to the administration of an agent in four of seven applicable patient records reviewed.
Patient # 1 was admitted on May 24, 2021 and was still active at the time of the inspection. There was no documentation, in the client record, of an emergency contact prior to the administration of an agent.
Patient # 2 was admitted on May 26, 2021 and was still active at the time of the inspection. There was no documentation, in the client record, of an emergency contact prior to the administration of an agent.
Patient # 4 was admitted on April 8, 2021 and was discharged on April 13, 2021. There was no documentation, in the client record, of an emergency contact prior to the administration of an agent.
Patient # 7 was admitted on January 29, 2021 and was discharged on February 3, 2021. There was no documentation that the verification of the patient's identity was completed in the client record prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency Contact
Intake: Admission coordinator will review Patient #1 , #2 , #4 and # 7 with assigned intake worker(s) to reinforce the significance of obtaining emergency contact information from each admission for disclosure of information contained in the client record by June 16, 2021.
Admission coordinator will review all active clients by June 18th to verify that an emergency contact is on file, if not documented the clinical supervisor will input the emergency contact information.
Admission coordinator will provide an in-service training by June 18, 2021. Regarding the documentation of emergency contact information
Admission coordinator will conduct frequent audits of 5 intake admissions a week to validate staff is obtaining emergency contact information beginning June 18, 2021
Admission coordinator will document outcome of emergency contact chart audit in Performance Improvement quarterly by July 18, 2021.
Client identification
Clinical supervisor Admission coordinator will review patient #7 with assigned intake worker to reinforce the significance of verifying patient identity.
Admission coordinator will review all active clients by June 18th to verify that a client verification is on record. If it is not on record clinical supervisor will verify clients' identification by completing the narcotic verification form.
Admission coordinator will conduct frequent audits of 5 intake admissions a week to validate staff is verify clients' identification by completing the narcotic verification form by June 18, 2021
Admission coordinator will document outcome of client identification chart audit in Performance Improvement quarterly by June 18, 2021.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug prior to admission for detoxification treatment in two of seven applicable patient records reviewed.
Patient # 6 was admitted on January 22, 2021 and was discharged on January 27, 2021. The client record documented that the determination of whether an individual is currently physiologically dependent upon a narcotic drug was conducted via telehealth services, not in person.
Patient # 7 was admitted on January 29, 2021 and was discharged on February 3, 2021. The client record documented that the determination of whether an individual is currently physiologically dependent upon a narcotic drug was conducted via telehealth services, not in person.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
# Vice ?President of nursing reviewed importance of face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug prior to admission for detoxification treatment to narcotic treatment physicians by June 18, 2021.
# Nursing department overseen by Vice-president will perform chart audits monthly to verify that narcotic treatment physician make face-to-face determination of whether an individual(s) is currently physiologically dependent upon a narcotic drug prior to admission for detoxification treatment by June 2021.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation in one of seven patient records reviewed.
Patient # 7 was admitted on January 29, 2021 and was discharged on February 3, 2021. There was no completed psychosocial evaluation documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will meet with patient # 7's assigned counselor about following: Policy: 706.106 Bio-Psychosocial Assessment Process to prevent further occurrences of no psychosocial evaluation in patient record by June 18, 2021
# *Clinical Supervisor will conduct random audits of three ( 3)charts per clinician each month to validate that staff is following Policy: 706.106 Bio-Psychosocial Assessment Process to prevent further occurrences of no psychosocial evaluation in patient record by June 18, 2021
*Clinical Supervisor will document outcome chart audits in Performance Improvement report quarterly by July 9 ,2021.
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