INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted from August 21 - 22, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System - Torre De La Raza, 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:
|
Plan of Correction
|
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.
|
Observations
Based upon the physical plant inspection, the facility failed to 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 findings include:
The rear visitor's parking lot is shared between several programs contained within the project. A physical plant inspection was conducted on August 9, 2012 following the Administrative Site Visit , from approximately 12:00 PM to 12:30 PM and again upon arriving at the facility on August 22, 2012. The parking lot contained several potholes and loose macadam / stones from the potholes, which presented a hazard to residents, employees, and / or visitors.
The findings were confirmed by the Building Director.
This is a repeat citation. The program was cited for noncompliance with this standard during the August 18, 2011 inspection.
|
Plan of Correction
The visitor's parking lot will be resurfaced on or before October 31, 2012. The Facilities director will be responsible for insuring that the lot is inspected on a regular basis and that new potholes are repaired as they occur.
|
711.53(a)(8) LICENSURE Work as Therapy
711.53. 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 contained in 115.32 (relating to contents), the client record shall include the following:
(8) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
|
Observations
Based upon a review of the facility's Policy & Procedures (P&P) Manual and client records, the facility failed to verify that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
The facility's P&P Manual was reviewed as part of an Administrative Review conducted from August 6 - 8, 2012. As per the P&P Manual, clients engage in the clean up and maintenance of their personal surroundings as well as common group areas.
Eight client records requiring verification that work done by the client is an integral part of their treatment plan were reviewed from August 21 - 22, 2012. Eight of eight records, specifically #'s 1, 2, 3, 4, 5, 6, 7, and 8, did not contain documentation that verified that work completed by the clients was an integral part of their treatment plan.
Client # 1 was admitted on July 13, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 2 was admitted on July 10, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 3 was admitted on July 16, 2012, and was discharged on August 20, 2012. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 4 was admitted on July 30, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 5 was admitted on July 3, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 6 was admitted on July 25, 2012, and was still an active client during the inspection. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 7 was admitted on November 14, 2011, and was discharged on December 15, 2011. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
Client # 8 was admitted on November 10, 2011, and was discharged on December 16, 2011. As of the date of inspection, the record did not contain documentation that verified that work completed by this client was an integral part of their treatment plan.
The findings were confirmed by the Clinical Director during the exit interview.
|
Plan of Correction
The clinical supervisor will review the policy regarding work therapy and its documentation with the clinical staff by September 30, 2012. The clinical supervisor will monitor all treatment plans during the month of October to ensure that documentation is complete. The unit will be in full compliance bey October 31, 2012. The clinical supervisor will conduct random monitoring of Treatment plans to ensure ongoing compliance. |
711.53(c)(1)(ii) LICENSURE Staff Access to client records
711.53. 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 is not limited to:
(ii) Staff access to client records.
|
Observations
Based upon a review of the Policy & Procedures (P&P) Manual and the physical plant inspection, the facility failed to follow its own policy that limited staff access to client records.
The findings include:
The P&P Manual was reviewed as part of an Administrative Review that was conducted from August 6 - 8, 2012. The policy regarding staff access to client records indicates that the Medical Records Department is responsible for maintaining a list of personnel authorized to have access to client records.
The physical plant inspection was conducted on August 21, 2012, from approximately 2:30 PM to 3:15 PM.
Client records were stored in a file cabinet that was located in a room on the "3 South" wing of the hospital. At the time of inspection, the file cabinet could not be locked and the room that contained the file cabinet did not have a door. Therefore, there was no way to limit access to client records to only those staff members who were authorized to have access to them.
The findings were confirmed by the Facility Director.
|
Plan of Correction
The file room on 3South was secured with a lock on August 22, 2012. A list of staff with access was placed on the door on August 22, 2012. The clinical supervisor will monitor the area to determine that access is limited to appropriate staff members. |