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- Return Program 1&2 was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
This report is a result of an on-site licensure renewal inspection conducted on August 16-17, 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 - 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)(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 requiring documentation of HIV/AIDS or TB/STD training were reviewed. There was no documentation of HIV/AIDS or TB/STD training in two of eight employee records reviewed, specifically, records #7 and 8.
Employee #7, a support staff member, was hired January 14, 2008 and was required to have HIV/AIDS & TB/STD training by January 14, 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 October 6, 2008 and was required to have HIV/AIDS & TB/STD training by October 6, 2010. 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.
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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. |
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, 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:
On August 16, 2011, psychosocial evaluations in eight client records were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7 and 8. 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 client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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."
Client # 1 was admitted on 7/5/11. The psychosocial evaluation in client record # 1 dated 7/7/11 did not include the client's assets and strengths, coping mechanisms and negative factors.
Client # 2 was admitted on 7/6/11. The psychosocial evaluation in client record # 2 dated 7/7/11 did not include the client's assets and strengths, support systems, coping mechanisms and negative factors.
Client # 3 was admitted on 6/22/11. The psychosocial evaluation in client record # 3 was not dated and 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 6/20/11. The psychosocial evaluation in client record #4 dated 6/21/11 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 # 5 was admitted on 1/24/11. The psychosocial evaluation in client record #5 dated 1/25/11 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 1/11/11. The psychosocial evaluation in client record #6 dated 1/5/11 did not include the client's assets and strengths, support systems, coping mechanisms and negative factors.
Client # 7 was admitted on 3/7/11. The psychosocial evaluation in client record #7 dated 3/10/11 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 3/7/11. The psychosocial evaluation in client record #8 dated 3/8/11 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. |
711.53(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 in four of four client records.
The findings include:
On August 16, 2011, four client records requiring aftercare plans in 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, # 5, 6, 7 and 8.
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 # 5 was admitted on 1/24/11. The aftercare plan in client record # 5 dated 3/30/11 did not include future goals with time frames.
Client # 6 was admitted on 1/11/11. The aftercare plan in client record # 6 dated 4/29/11 did not include future goals with time frames.
Client # 7 was admitted on 3/7/11. The aftercare plan in client record # 7 dated 5/6/11 did not include future goals with time frames.
Client # 8 was admitted on 3/7/11. The aftercare plan in client record # 8 dated 5/5/11 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. |