INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System IOP-CAP 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 and a plan of correction is due on September 24, 2010.
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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:
Six personnel records were reviewed on August 11, 2010 through August 16, 2010 and the staffing requirements facility summary report was reviewed on August 11, 2010 through August 12, 2010. There was no documentation of HIV/AIDS or TB/STD training in two employee records. Of the two, one 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 #4 was hired June 1, 2007 and was required to have HIV/AIDS & TB/STD training by June 1, 2007. There was no documentation of HIV/AIDS training in the employee's record as of August 16, 2010.
Employee #6 was hired April 6, 2006 and was required to have HIV/AIDS & TB/STD training by April 6, 2008. There was no documentation of HIV/AIDS training documented in the staffing requirements facility summary report dated August 16, 2010.
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Plan of Correction
Training
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 insure 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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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 tour of the facility ' s physical plant and an interview with the facility director, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The facility was required to ventilate all toilets and wash rooms by exhaust fan or window. The facility did not ventilate one of the two unisex toilets in the waiting area.
The facility director confirmed that ventilation was not provided in one of the toilets in the waiting area.
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Plan of Correction
All the vent motors were replaced during the survey. The Director of Plant Facilities will place the monitoring of vent motors as a part of the monthly preventative maintenance rounds.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
A tour of the facility's physical plant was conducted on August 25, 2010 at approximately 11:00 AM. A portable space heater was observed in a counseling office.
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Plan of Correction
Heating and Cooling
The space heaters were immediately removed from the premises. The staff member was reminded of regulations regarding space heaters.
The clinical supervisors will monitor compliance with this regulation on a ongoing basis. The program will be in compliance immediately.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to conduct unannounced fire drills at least once per month.
The findings include:
The facility fire drill record did not include any record of a fire drill for June 2010.
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building..
The staff person questioned confirmed that there was no documentation of a June 2010 Fire drills, nor were there any observation sheets completed for December 31, 2009
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill records covering the period from September 2009 through July 2010, and interview with facility staff, both occurring on August 11, 2010, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
The fire drill record indicated that the fire pump went off on December 31, 2009 at 5:54 AM; however there were no Observation Worksheets completed for any floors of the Tower Building including.
The fire drill conducted on November 27, 2009 failed to document the exit route used.
The fire drill conducted on January 18, 2010 did not identify the exit route.
The fire drill record of February 25, 2010 only contained documentation for the ninth floor of the Tower building.
The fire drill conducted on April 6, 2010 did not include the number of participants.
The fire drill conducted on May 26, 2010 had a note that the indicated no evacuation due to early morning.
The staff person questioned confirmed the findings.
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Plan of Correction
As of 9/13/2010, the Director of Facilities will name a new Fire Marshall for Girard Medical Center Campus. The new Fire Marshall will be responsible for scheduling all fire drills in compliance with the DOH Dvision of Drug and Alcohol standards.
The Fire Marshall will also be responsible to assure all documentation regarding the fire drill and the post fire drill critique are completed and filed. Compliance will be assured by September 30, 2010.
The Fire Marshall will also assure that all fire extinguishers are tagged and inspected monthly.
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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 a review of client records, the facility failed to document a psychosocial evaluation to include the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impressions in eight of eight client records reviewed.
The finding includes:
Eight records were reviewed on August 24, 2010. Psychosocial evaluations were required in Eight records reviewed.
Client records #1 and 2 failed to document the client ' s assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client records #3 failed to document the client's composite picture, client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impression.
Client records #3 failed to document the client's composite picture, client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client attitude toward treatment and the counselor conclusions/impression.
Client records #5, 6, 7 and 8 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impression.
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Plan of Correction
Psychosocial Evaluations
The Director of Outpatient Psychiatry will develop a three hour training sessions on completing psychosocial evaluations and will provide the training to all clinical staff by November 30, 2010.
A psychologist from the Outpatient Department will conduct random reviews of evaluations and meet with clinical staff to review case formulations/evaluations for the next 90 days.
The clinical supervisors will review three cases per month of each clinician for the next 90 days, focusing on psychosocial evaluations.
Ongoing monitoring will be conducted by the clinical supervisors and full compliance will occur by December 31, 2010.
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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 support services in five of eight records reviewed.
The findings include:
Eight client records were reviewed on August 25, 2010. Support services were required in eight client records. The facility did not document support services in client records #1, 4, 5, 6 and 7.
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Plan of Correction
Support Service
The training department will provide in service training on treatment plans and the inclusion of support service in planning by October 15, 2010.
The clinical supervisor will provide ongoing supervision and review with focus review on support services for the next ninety days. The program will be fully compliant by November 30, 2010.
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711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a tour of the facility ' s physical plant and an interview with the facility director, the facility failed to maintain the confidentiality of the clients ' identity.
The findings include:
A tour of the facility ' s physical plant and an interview with the facility director was conducted on August 25, 2010 at approximately 11:00 AM. The licensing specialist observed a client sign-in sheet, in the reception area, with the first and last names of a client presently or previously at the facility.
The facility director confirmed the practice of having all clients sign the sign-in sheet upon arrival.
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Plan of Correction
Confidentiality
The sign in sheet was discontinued effective immediately.
The clinical supervisor will review confidentiality regulations in staff meeting on/before October 15, 2010.
The clinical supervisor will monitor the enforcement of this process.
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