INITIAL COMMENTS
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This report is a result of a telephone complaint investigation that was conducted on June 12 -13, 2014, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the investigation, North Philadelphia Health System "Goldman Clinic", 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 supervisory review:
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Plan of Correction
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a complaint investigation and a telephone conversation with the Facility Director, the facility failed to submit an Unusual Incident Report to the Department for the incident that occurred on May 30, 2014 when a client brought a firearm into the facility.
The findings include:
Patient called the DDAP office on June 12, 2014 at 11:16 am to state that on May 30, 2014 he was escorted off the premises of the Goldman Clinic and was involuntarily discharged from the program. Patient stated he did not know the reason why he was terminated. The patient gave DDAP permission to contact the facility and intervene on his behalf.
Contact was made with the Facility Director on June 13, 2014 at 1:30 pm. The Facility Director stated that during the patient's individual session, the patient placed a firearm and the clip on the desk of his counselor. Due to the threat of violence, the patient was administratively discharged.
A review of Incident Reports previously submitted to DDAP from this facility was conducted. The facility failed to submit an Incident Report for this occurrence.
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Plan of Correction
1. Goldman Clinic staff will abide by Policy 715.28 Subject : Unusual Incident Report, which states "The unusual incident report is filied with the Depeatment of Health and Community Behavioral Health within 48 hr's of event occuring. Incident reports will be forwarded to CBH , Department of Health , GMC Security and all other entities involved" by 8/15/2014
2. Policy 715.28(a)Unusual Incident Protocol will be revised to inculed filing a unusual report with Department of Health within 48 hr., if a incident occurs by 8/15/2014
3. Supervisors will perform a in-service with staff during treatment team meetings by 8/15/2014
4. Director will monitor compliance to Policy 715.28 on a monthly basis by reviewing incident report book.
5. Clinic supervisors will complete incident report form within timeframe and forward to CBH , DOH and other internal department as needed . |