INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10 through September 11, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Philadelphia Health Management Corporation/Chances 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 October 12, 2007.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of the project director's responsibilities in the organization on 9/10/07, the project director did not perform the duties for this position and did not report directly to the board. The project director reports to Philadelphia Health Management Corporation senior management team.
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Plan of Correction
PHMC President and CEO has been appropraitly named as the Project Director for CHANCES, and in that capacity will report directly to the PHMC Board. |
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 the physical plant inspection on 9/11/07 at 11:45 am, the facility failed to ensure all heaters were permanently mounted or installed. A portable space heater was located in employee #5's counseling office.
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Plan of Correction
Management was not aware of the presence of a space heater in a therapist's office. Heater was immediatly removed, and a memo dated 10/9/07 was issues to all staff reminding them of the portable space heater policy. Disciplinary action will be enforced for any future violations of the policy. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review administrative documentation and staff interview on 9/10/07, the governing body failed to document an annual report and make it available to the public.
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Plan of Correction
The Corporate PHMC report was not released in time to be presented for the audit. Program Director is currently aware that in future instances when the Corporate PHMC report is not completed by 6 months after the fiscal year, CHANCES will need to make available to the public its own annual report. Program Director will create the report and post an announcement in a local paper and/or on the PHMC website for public access and viewing. For the last fiscal year, CHANCES will make its report available to the public by December 31st of the new fiscal year. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review administrative documentation and staff interview on 9/10/07, the governing body failed to document an annual report including activities and accomplishments of the preceding year.
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Plan of Correction
As mentioned in plan of correction for #0135, an annual report will be completed by Program Director for CHANCES when the Corporate PHMC report is unavailable. The report will include activities and accomplishments of the preceding years. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review administrative documentation and staff interview on 9/10/07, the governing body failed to document an annual report including a financial statement of income and expenses.
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Plan of Correction
As mentioned in plan of correction for #0135, an annual report will be completed by Program Director for CHANCES when the Corporate PHMC report is unavailable. The report will include a financial statement of income and expenses for the preceding year. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review administrative documentation and staff interview on 9/10/07, the governing body failed to document an annual report including the names of officers, directors and principal shareholders
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Plan of Correction
As mentioned in plan of correction for #0135, an annual report will be completed by Program Director for CHANCES when the Corporate PHMC report is unavailable. The report will include the names of officers, directors and principal shareholders. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection on 9/11/07 at 11:45 am and staff interview, the facility failed to secure client records within locked storage containers. Active client records were stored in an unlocked container in an unsecured staff room.
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Plan of Correction
Client records had been stored in a lockable file cabinet in an office accessible only to staff. The cabinets were locked after hours. However, management will now ensure that file cabinets are locked at all times, and only clinical staff needing access to client records will have a copy of the key to the cabinet. Copies of keys were made and distributed to staff on 10/12/07. Starting 11/15/07, Administrative Assistant will randomly check cabinets at least once weekly, maintain a log of these random checks, and will inform Director immediatly if the cabinet was left unlocked. Director will follow-up with the last staff member who retrieved or returned a file and review the policy with them. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records on 9/11/07, the facility failed to obtain an informed consent from clients in five of five records reviewed, #1, 2, 3, 4 and 5. Clients signed the Philadelphia Health Management Corporation Patient Acknowledgment and Consent form which included language that exceeded the information allowed under 4 Pa. Code 255.5.
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Plan of Correction
The informed consent referred to in this citation is the PHMC corporate HIPAA patient aknowledgment and consent form. The form was amended with 4 Pa. Code 255.5 language restricting what can be released. The revised form is currently being used for all new admissions to CHANCES. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on 9/11/07, the facility failed to document a complete drug and alcohol history in five of five client records reviewed, #1, 2, 3, 4 and 5. The lengths and patterns of drug and alcohol use were not documented.
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Plan of Correction
Program Director and Director of Quality Management have already met to discuss revisions to the current assessment tools to include a more comprehensive review of client's progression and patterns of drug use. Forms will be revised, and staff will receive training on the new forms by 11/15/07. In addition, PHMC Quality Management team will conduct quarterly chart reviews to ensure compliance with this standard. Results will be presented on the same day to the Clinical Diretor to follow-up on noted deficiencies during staff member's next supervision. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records on 9/11/07, the facility failed to document a complete personal history in three of five records reviewed, #1, 2 and 3. The clients's employment history reflected only the last job held by the client or the statement "under the table" for employer with no additional information provided. The educational history was also missing.
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Plan of Correction
Program Director and Director of Quality Management will review assessment tools by 11/15/07 to improve how the employment-related questions are phrased to make it easier to gather the information. In addition, Program Director will conduct a training for staff by 11/15/07 to improve their ability to gather this information and to request that they make every effort to obtain it, and/or to indicate client's refusal or inability to provide the information. In addition, PHMC's Quality Management team will conduct quarterly chart reviews to ensure compliance with this standard. Results will be presented on the same day to the Clinical Diretor to follow-up on noted deficiencies during staff member's next supervision. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) 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 on 9/11/07, the facility failed to document a complete treatment plan update in two of four client records reviewed, #2 and 3. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the treatment plan.
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Plan of Correction
A treatment plan training was conducted by Clinical Director on October 22nd. The training emphacised the importance of a thorough and specific assessment of the clients progress towards their goals as indicated in their treatment plan. In addition, PHMC Quality Management team will conduct quarterly chart reviews to ensure compliance with this standard. Results will be presented on the same day to the Clinical Diretor to follow-up on noted deficiencies during staff member's next supervision. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records on 9/11/07, the facility failed to document goals with time frames on the aftercare plan in three of three records reviewed, #5, 7 and 8. Support services were not documented on one of three, #8.
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Plan of Correction
The aftercare plan will be revised by 11/15/07 to include better prompts for therapists to include time frames and support services for aftercare goals. In addition, a staff training on the aftercare planning process will be conducted by Clinical Director by 11/15/07. In addition, PHMC Quality Management team will conduct quarterly chart reviews to ensure compliance with this standard. Results will be presented on the same day to the Clinical Diretor to follow-up on noted deficiencies during staff member's next supervision. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records on 9/11/07, the facility failed to document discharge summaries within the required time frame in four of four client records reviewed, #5, 6, 7 and 8. Discharge summaries were not dated. The reasons for treatment were not documented in three of four client records reviewed, #5, 6 and 7.
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Plan of Correction
The discharge summary form has now been corrected to include a date line next to the signature line, and staff will be using the revised form for all future discharges. In addition, Clinical Director will be conducting a training on the aftercare planning process by 11/15/07, and will emphacise the need for staff to include reasons for treatment on the form. In addition, PHMC's Quality Management team will conduct quarterly chart reviews to ensure compliance with this standard. Results will be presented on the same day to the Clinical Director to follow-up on noted deficiencies during staff member's next supervision. |