INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 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 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:
Twenty three personnel records were reviewed on August 8, 2011 through August 9, 2011. There was no documentation of HIV/AIDS or TB/STD training in seven employee records. Of the seven, four was to have HIV/AIDS and TB/STD training within the first year of employment and the rest was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #6 was hired May 6, 2009 and was required to have HIV/AIDS & TB/STD training by May 6, 2010. There was no documentation of TB/STD training in the employee's record as of August 9, 2011.
Employee #11 was hired November 2009 and was required to have HIV/AIDS & TB/STD training by November 2010. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of August 9, 2011.
Employee #17 was hired August 9, 2010 and was required to have HIV/AIDS & TB/STD training by August 9, 2011. There was no documentation of HIV/AIDS training in the employee's record as of August 9, 2011.
Employee #19 was hired July 9, 2010 and was required to have HIV/AIDS & TB/STD training by July 9, 2011. There was no documentation of HIV/AIDS training in the employee's record as of August 9, 2011.
Employee #21 was hired April 1, 2009 and was required to have HIV/AIDS & TB/STD training by April 1, 2011. There was no documentation of HIV/AIDS training in the employee's record as of August 9, 2011.
Employee #22 was hired May 12, 2008 and was required to have HIV/AIDS & TB/STD training by May 12, 2010. There was no documentation of HIV/AIDS training in the employee's record as of August 9, 2011.
Employee #23 was hired October 15, 1985 and was required to have HIV/AIDS & TB/STD training by October 15, 1987. There was no documentation of HIV/AIDS & TB/STD 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 17, 2010 licensing inspection. The facility's plan of correction submitted on September 20, 2010 and approved on September 23, 2010 stated the following:
" The New Employee Orientation will be modified to include HIV/AIDS and First Aid training along with the TB/STD and CPR training in order to ensure that all new hires obtain the DOH mandatory training requirements. The infection disease department will be responsible for providing HIV/AIDS and the education department will be responsible for providing First Aid. The modification will take place by November 2010.
By December 31, 2010 all current staff who is not compliant for training will receive the DOH mandatory training.
The Program Directors and the AVP or nursing will be responsible for ensuring that all staff has obtained required training. "
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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. |
705.22 (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 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. |
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 a physical plant inspection, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
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 facility did not ventilate one of the two unisex wash rooms in the waiting area on the third floor.
The findings were confirmed by a facility director on August 18, 2011.
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Plan of Correction
This deficieny was corrected prior to the end of the survey. Environmental rounds will be completed on a montly basis to ensure ongoing compliance with this policy. The unit administration will be responsible for ensuring that rounds are conducted. Full compliance will be obtained by 9/30/11. |
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 the review of client records, the facility failed to document a psychosocial evaluation in accordance with facility policy to include a composite picture of the individual in relationship to the collected historical information and/or facility time frames.
The findings include:
From August 17-19, 2011, twenty client records requiring psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation to include a composite picture of the individual in relation to the collected historical information, as per facility policy, in twenty of twenty client records reviewed, specifically, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 17, 18, 19, 20, 21 and 22.
The facility's policy titled " Bio-Psychosocial " states:
"Within the first thirty days, the Counselor completes:
The Psychosocial History and Evaluation - this provides a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation."
Client # 1 was admitted on 1/10/11. A psychosocial evaluation was due to be completed by 2/10/11, but at the time of inspection client record # 1 did not contain a psychosocial evaluation.
Client # 2 was admitted on 4/5/11. A psychosocial evaluation was due to be completed by 5/5/11, but the psychosocial evaluation in client record # 2 was dated 5/16/11. Additionally, the psychosocial evaluation did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client ' s appearance and behavior during the initial interview.
Client # 3 was admitted on 7/6/11. The psychosocial evaluation in client record # 3 dated 8/2/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client ' s appearance and behavior during the initial interview.
Client # 4 was admitted on 5/27/11. A psychosocial evaluation was due to be completed by 6/27/11, but the psychosocial evaluation in client record # 4 was dated 8/2/11. Additionally, the psychosocial evaluation did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 5 was admitted on 5/13/11. The psychosocial evaluation in client record # 5 dated 5/13/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 6 was admitted on 5/24/11. The psychosocial evaluation in client record # 6 dated 5/23/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 7 was admitted on 8/8/11. The psychosocial evaluation in client record # 7 dated 8/10/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 8 was admitted on 7/6/11. The psychosocial evaluation in client record # 8 was not dated and it 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.
Client # 9 was admitted on 3/24/11. The psychosocial evaluation in client record # 9 dated 4/19/11 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.
Client # 10 was admitted on 4/25/11. The psychosocial evaluation in client record # 10 dated 5/3/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 11 was admitted on 2/11/11. A psychosocial evaluation was due to be completed by 3/11/11, but the psychosocial evaluation in client record # 11 was dated 5/3/11. Additionally, the psychosocial evaluation did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 12 was admitted on 4/14/11. The psychosocial evaluation in client record # 12 dated 4/19/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 13 was admitted on 4/22/11. The psychosocial evaluation in client record # 13 dated 5/4/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 14 was admitted on 7/14/11. The psychosocial evaluation in client record # 14 dated 8/8/11 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 17 was admitted on 7/18/11. The psychosocial evaluation in client record # 17 dated 7/27/11 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.
Client # 18 was admitted on 3/11/11. The psychosocial evaluation in client record # 18 dated 4/6/11 did not include the client ' s assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 19 was admitted on 12/15/10. The psychosocial evaluation in client record # 19 dated 12/16/10 did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
Client # 20 was admitted on 6/29/11. A psychosocial evaluation was due to be completed by 7/29/11, but at the time of inspection client record # 20 did not contain a psychosocial evaluation.
Client # 21 was admitted on 11/29/10. The psychosocial evaluation in client record # 21 dated 12/23/10 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 # 22 was admitted on 4/27/11. A psychosocial evaluation was due to be completed by 5/27/11, but the psychosocial evaluation in client record # 22 was dated 6/2/11. Additionally, the psychosocial evaluation did not include the client's assets and strengths, support systems, coping mechanisms, negative factors and conclusions regarding the client's appearance and behavior during the initial interview.
The findings were confirmed by the facility director on August 19, 2011.
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Plan of Correction
The NPHS education department will provide all clinical staff with a series of trainings on how to complete and document the psychosocial evaluation. The trainings will be completed by October 31, 2011.
The training will address client's strength; client's assets; attitude, and negative factors which may inhibit treatment.
During weekly supervision, the clinical supervisors will review 3 current records to assure proper and timely completion of psychosocial evaluation.
Supervision sessions coducted by the clinical supervisors over the next 90 days will focus on the evaluations timely and correct documentation. |
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 the review of client records, the facility failed to document treatment plans to include proposed types of supportive services in seven of nineteen records.
The findings include:
From August 17-19, 2011, nineteen client records requirinf treatment plans in were reviewed for proposed types of support services. The facility did not document treatment plans to include a proposed type of support service in seven of 19 client records reviewed, specifically, # 4, 5, 9, 11, 13, 18 and 22.
Client # 4 was admitted on 5/27/11. The treatment plan in client record # 4 dated 6/2/11 did not include a proposed type of support service.
Client # 5 was admitted on 5/13/11. The treatment plan in client record # 5 dated 5/19/11 did not include a proposed type of support service.
Client # 9 was admitted on 3/24/11. The treatment plan in client record # 9 dated 4/19/11 did not include a proposed type of support service.
Client # 11 was admitted on 2/11/11. The treatment plan in client record # 11 dated 2/18/11 did not include a proposed type of support service.
Client # 13 was admitted on 4/22/11. The treatment plan in client record # 13 dated 5/20/11 did not include a proposed type of support service.
Client # 18 was admitted on 3/11/11. The treatment plan in client record # 18 dated 3/16/11 did not include a proposed type of support service.
Client # 22 was admitted on 4/27/11. The treatment plan in client record # 22 dated 5/27/11 did not include a proposed type of support service.
This was confirmed byt the facility director on August 19, 2011.
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Plan of Correction
All Clinical Staff will participate in a series of 3 in-service trainings to address written documentation on treatment plans and the inclusion of support services. The trainings will be completed by October 31, 2011.
While providing weekly supervision, during the next 90 days, the clinical supervisors will review records and focus on the documentation of support services. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates to include an assessment of the client's progress.
The findings include:
From August 17-19, 2011, thirteen client records requiring treatment plans updates were reviewed. The facility did not document treatment plan updates to include an assessment of the client's progress in seven of thirteen records reviewed, specifically, # 1, 9, 11, 12, 18, 19 and 22.
Client # 1 was admitted on 1/10/11. The comprehensive treatment plan in client record # 1 was dated 3/10/11, but at the time of inspection, the record did not contain a treatment plan update.
Client # 9 was admitted on 3/24/11. The treatment plan updates in client record # 9 dated 6/13/11, 7/13/11 and 8/12/11 did not include an assessment of the client's progress.
Client # 11 was admitted on 2/11/11. The treatment plan update in client record # 11 dated 7/26/11 did not include an assessment of the client's progress.
Client # 12 was admitted on 4/14/11. The treatment plan update in client record # 12 dated 6/21/11 did not include an assessment of the client's progress.
Client # 18 was admitted on 3/11/11. The treatment plan updates in client record # 18 dated 4/14/11, 6/13/11 and 8/12/11 did not include an assessment of the client's progress.
Client # 19 was admitted on 12/15/10. The treatment plan updates in client record # 19 dated 1/13/11 and 3/30/11 did not include an assessment of the client's progress.
Client # 22 was admitted on 4/27/11. The comprehensive treatment plan in client record # 22 was dated 5/27/11, but at the time of inspection, the record did not contain a treatment plan update.
The findings were confirmed by the facility director on August 18, 2011.
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Plan of Correction
Treatment plan updates will be completed on or before 60 days.
All clinical staff will complete a 2 hour training on the update of treatment plans including how to document client's progress and assessment.
All clinical staff will complete retraining by October 31, 2011.
During weekly supervision, the clinical supervisors will review 3 charts to ensure that this process is being followed. Clinical staff following this process will not receive extra training. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans.
The findings include:
On August 17, 2011, four client records requiring aftercare plans were reviewed. The facility did not document aftercare plans in four of four records reviewed, specifically, client records # 24, 25, 28 and 29.
Client # 25 was admitted on 12/26/87 and discharged on 1/11/11, but at the time of inspection client record # 25 did not contain an aftercare plan.
Client # 28 was admitted on 1/14/08 and discharged on 5/25/11, but at the time of inspection client record # 28 did not contain an aftercare plan.
Client # 29 was admitted on 4/6/10 and discharged on 5/9/11, but at the time of inspection client record # 29 did not contain an aftercare plan.
Additionally, client # 24 was admitted on 1/11/07 and discharged on 5/31/11, but the aftercare plan in client record # 24 dated 3/30/11 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 policy on aftercare plan has been revised. The VP of Behavioral Health Services has revised the policy and procedure to read:
It is the policy of NPHS, Goldman Clinic to complete discharge instructions on all consumers who complete the program. A
Aftercare plans will not be completed on consumers who AFA, AWOL, or jailed. When completed, aftercare plans will include short and long term goals with time frames.
The Clinical staff will receive an in-service on documentation on aftercare plan and the update of the policy by October 15, 2011.
The clinical supervisors and program director will review and discharges to ensure the aftercare plan is being completed on consumers who complete the program. |
711.95(b) LICENSURE Efficient Retrieval of Data
711.95. Uniform Data Collection System.
(b) A data collection system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
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Observations
Based on observation, the facility failed to demonstrate a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.
The findings include:
On August 17, 2011 at approximately 8:45 AM, the Licensing Specialist received client census reports for active and discharged clients, but the reports did not include the clients ' admission dates as had been requested.
At approximately at 10:00 AM, the Licensing Specialist received a second client census report which did include the admission dates for the active and discharged clients.
At approximately 10:10 AM, the Licensing Specialist provided the facility with a list of client records to be reviewed, but the Licensing Specialist did not receive these records until approximately 12:00 noon.
An interview with the facility director on August 17, 2011, confirmed that the facility did not demonstrate an efficient data collection and record keeping system.
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Plan of Correction
The Goldman Clinic had purchased and installed a new client information system.
The new system will be able to provide us with an admission and discharge report, to include the client's name, admission; discharge date and reason for discharge.
Furthermore, the discharge record room will be reorganized and relocated into a new and larger medical records room in the GMC main building allowing for easier access and retrival.
The new client information system and the re-organization of the discharge room will allow for an efficient retrieval of data.
The electronic system installation will be completed by September 30, 2011; the relocation of the record room will be completed by November 30, 2011.
The program director and the medical record analyst will insure compliance with this procedure through quality assurance record review process.
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