INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8, 2013 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed 12 clock hours of required training in one of one personnel record reviewed.
The findings include:
From August 6, 2013 to August 7, 2013, one personnel record requiring documentation of 12 clock hours of training was reviewed. The facility failed to provide documentation of 12 clock hours of training in one of one personnel record reviewed, specifically, personnel record # 3.
Employee # 3 is a clinical supervisor and was hired for his current position on November 10, 2007. Employee # 3 was required to complete 12 clock hours of annual training hours by December 31, 2012. However, personnel record # 3 only had documentation of 6 clock hours of annual training for the January 1, 2012 to December 31, 2012 training year as of August 7, 2013.
The findings were confirmed during an interview with the Vice President on August 7, 2013 at approximately 9:30 A.M.
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Plan of Correction
1.Director will develop with clinical supervisors an annual education plan January of each year.
2.Based on each clinical supervisors' continuing education needs Director will assist with locating trainings
3.During monthly supervision sessions Director will review each clinical supervisor's progress in obtaining education clock hours required by state regulations.
4.Director will review and document with each clinical supervisors progress obtaining relevant training in their annual performance evaluation
5.Effective August 26 , 2013 , Director will implement a plans of action for observations # 0079
6. Director will be responsible for monitoring all the clinical supervisors training hours and make sure that all the clinical supervisors complete the required annual training hours by December 31 each year. |
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 observations on August 7, 2013, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
A physical plant inspection was conducted on August 7, 2013, 4 client bathrooms, 2 public bathrooms, and 3 staff bathrooms were inspected. From approximately 10:00 A.M. to 11:00 A.M. and from approximately 2:09 P.M. to 2:10 P.M., the facility failed to ventilate the following bathrooms by exhaust fan or window. The following are the bathrooms that were not ventilated by an exhaust fan or window:
1) The IOP unisex client bathroom on the 4 th floor near the elevators.
2) The two client unisex bathrooms on the 1st floor in the dispensing area.
The findings were confirmed during an interview with the safety officer and the director of maintenance on August 7, 2013 at approximately 2:11 P.M.
This is a repeat citation. The facility was cited on August 23, 2012 and August 17, 2012 for noncompliance with this standard.
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Plan of Correction
1.All Tower bathrooms will be inspected monthly by Facilities management staff. Facilities management staff will perform repairs to ventilation system in a timely manner.
2.Director of Goldman Clinic will perform daily facility checks to ensure proper functions of building operations
4.Effective August 26 , 2013 , Director will implement a plans of action for observations # P201
5.The unisex bathroom venting corrections was made on August 23, 2013.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of two personnel records reviewed.
The findings include:
From August 6, 2013 to August 7, 2013, two personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instructed staff in the use of the fire extinguisher upon staff employment in one of two personnel records reviewed, specifically, personnel record # 6.
Employee # 6 is a counselor and was hired on July 9, 2013. Employee # 6 was due to complete fire extinguisher training upon employment. However, personnel record # 6 did not include documentation of fire extinguisher training as of August 7, 2013.
The findings were confirmed during an interview with the Vice President on August 7, 2013 at approximately 9:30 A.M.
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Plan of Correction
1. North Philadelphia Health System's Human Resource department's oreintation monitor will oversee future employees attendance at fire extinguisher training and complete on time.Human Resource department will inform Goldman Clinic , if employee has missed fire extinguisher training. Clinic supervisor of the employee will reschedule the personnel for training and monitor attendance.
2.The two personnel who lacked documentation of fire exinguisher training will receieve instruction on the use of the fire extinguisher September 9,2013.
3.Documentation of attending and receiving instructs on the use of the fire extinguisher will be placed in their personnel records. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained upon employment to perform assigned tasks during emergencies in one of two personnel records reviewed.
The findings include:
From August 6, 2013 to August 7, 2013, two personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility failed to ensure that employees completed emergency training upon employment in one of two personnel records reviewed, specifically, employee # 6.
Employee # 6 is a counselor and was hired on July 9, 2013. Employee # 6 was due to complete emergency training by July 9, 2013; however, personnel record # 6 did not include documentation of emergency training as of August 7, 2013.
The findings were confirmed during an interview with the Vice President on August 7, 2013 at approximately 9:30 A.M.
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Plan of Correction
1.North Philadelphia Health System's Human Resource department 's orientation monitor will monitor future employees attendance at emergency training.Human Resource department will inform Goldman Clinic , if a employee has missed emergency training. Clinic supervisor of the employee will reschedule the personnel for training and monitor attendance.
2.The two personnel who lacked documentation of emergency training will receieve instruction on September 9,2013.
3.Documentation of attending and receiving emergency training will be placed in their personnel records.
1. The two personnel who lacked documentation of emergency training will instruction on September 9,2013.
2. Documentation of attending and receiving emergency training will be placed in their personnel records. |
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 a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in eleven of nineteen client records reviewed.
The findings include:
From August 7, 2013 to August 8, 2013, nineteen client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in eleven of nineteen records reviewed, specifically, client records # 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, and 12.
Client # 1 was admitted June 5, 2013. The individual treatment and rehabilitation plan was completed on June 12, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 2 was admitted April 3, 2013. The individual treatment and rehabilitation plan was completed on May 7, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 3 was admitted April 24, 2013. The individual treatment and rehabilitation plan was completed on May 31, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 4 was admitted Jun 19, 2013. The individual treatment and rehabilitation plan was completed on July 8, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 6 was admitted May 20, 2013. The individual treatment and rehabilitation plan was completed on June 17, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 7 was admitted April 8, 2013. The individual treatment and rehabilitation plan was completed on May 17, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 8 was admitted March 26, 2013. The individual treatment and rehabilitation plan was completed on April 26, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 9 was admitted May 22, 2013. The individual treatment and rehabilitation plan was completed on May 31, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 10 was admitted May 17, 2013. The individual treatment and rehabilitation plan was completed on May 20, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 11 was admitted March 7, 2013. The individual treatment and rehabilitation plan was completed on March 13, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
Client # 12 was admitted April 30, 2013. The individual treatment and rehabilitation plan was completed on May 17, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 8, 2013.
The findings were confirmed during an interview with the clinical supervisors on August 8, 2013 at approximately 1:40 P.M.
This is a repeat citation. The facility was cited on August 23, 2012 and August 17, 2011 for noncompliance with this standard.
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Plan of Correction
1.Clinical supervisors will perform in-services on Girard Medical Clinic Policy 711.91(b) (2) subject: Support Services on August 26, 2013 during treatment team.
2.A treatment plan addressing supports services will be developed with clients whose records were listed on the observations # 0967 effective August 26,2013
3.Clinical supervisors will audit charts during counselors' supervision and performance improvement data gathering to assess and insure staff's abilities to follow Policy 711.91(b)(2) procedures
4.Staffs who continue to need support services treatment plan development will receive additional supervision and off-site training effective August 26, 2013.
5.Clinical supervisor will monitor counselors' ability to document support services on the individual treatment and rehabilitation plan for their clients.If , the counselor lack skills to develop a supportive services treatment plan , clinical supervisor will do a in-services on the topic .
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711.93(a)(7) LICENSURE Follow-up Information
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:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of seven client records reviewed.
The findings include:
The facility policy states that the medical records secretary mails a follow-up 30 day questionnaire to the client within 30 days.
From August 7, 2013 to August 8, 2013, two client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information in two of seven records reviewed, specifically, client records # 18 and 23.
Client # 18 was admitted June 21, 2012 and discharged February 25, 2013. Follow-up information was due by March 27, 2013. However, client record # 18 did not include documentation of follow-up information as of August 8, 2013.
Client # 23 was admitted April 19, 2012 and discharged June 3, 2013. Follow-up information was due by July 3, 2013. However, client record # 23 did not include documentation of follow-up information as of August 8, 2013.
The findings were confirmed during an interview with the clinical supervisors on August 8, 2013 at approximately 1:40 P.M.
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Plan of Correction
1.Clinical Coordinator will complete follow ?up information in all the discharged client records as per regulation per Girard Medical Center Policy 711.94 (c) effective August 26, 2013.
2.Clinical supervisors will perform in-services on Girard Medical Clinic Policy 711.94(c) subject: Follow-up effective on August 26, 2013 during treatment team.
3.Clinical supervisors will audit charts during counselors' supervision and performance improvement data gathering to assess staff's abilities to follow Policy 711.94(c) follow ?up procedures.
4.Staffs who continue to need follow-up instruction will receive additional supervision and off-site training effective August 26, 2013.
5.Clinical supervisor and coordinator will be responsible making sure that follow-up information is completed on time for all discharged clients.
6. Clinical coordinator will complete follow-up information on Clients #18 and #23 on September 13 , 2013. Clinical coordinator will file follow-up in clients#18 and #23 charts. Director will make sure follow-up information is file in clients records # 18 and # 23 .
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