INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30, 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 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:
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observations on August 9, 2012 and August 30, 2012, 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 clients, employees and visitors.
The findings include:
A physical plant inspection was conducted on August 9, 2012. It was observed during the physical plant inspection from approximately 12:00 P.M. to 12:30 P.M., that there were areas in the employees' and visitors' parking lot that had potholes. Upon arriving at the facility on August 30, 2012 it was again observed that there were areas in the employees' and visitors' parking lot that had potholes.
The findings were confirmed during an interview with the building director on August 9, 2012 at approximately 12:30 P.M.
This is a repeat citation. The facility was cited on August 19, 2011 for noncompliance with this standard.
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Plan of Correction
All of the potholes in the visitor's and employee parking lot have been repaired. The Facilities director will be responsible for insuring that the lot is inspected on a monthly basis and that the lot is maintain in order to avoid and or repair new potholes. . |
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 30, 2012, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
A physical plant inspection was conducted on August 30, 2012. It was observed during this inspection at approximately 10:00 A.M., that one of the two unisex public bathrooms in the waiting room was not ventilated by an exhaust fan or window.
The findings were confirmed during an interview with the facility director on August 30, 2012 at approximately 10:00 A.M.
This is a repeat citation. The facility was cited on August 19, 2011 and August 25, 2010 for noncompliance with this standard.
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Plan of Correction
The ventilation unit in the unisex public bathrooms was replaced on 09/26/2012. Beginning October, the Clinical Supervisor will conduct monthly rounds to insure that the bathrooms ventilations' units are operating correctly and if needed will fixed or replaced as needed. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observations on August 30, 2012 , the facility failed to light interior exits and stairs at all times.
The findings include:
A physical plant inspection was conducted on August 30, 2012. It was observed during the inspection at approximately 10:30 A.M., that areas of the rear interior emergency exit stairs on the third floor of the building were not lighted.
The findings were confirmed during an interview with the safety officer on August 30, 2012 at approximately 10:30 A.M.
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Plan of Correction
All the burned light bulbs in the interior of the emergency exit stair on the third floor were replaced as of 09/03/12. Beginnig 10-01-12 the Fire Marshal will conduct monthly inspection and replace any burned light bulbs as needed on an ongoing basis in the interior exits and stairs. |
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 that included an assessment of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment. Also, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Bio-Psychosocial" states:
"A Psycho-Social Assessment is completed on all patients in the Outpatient Alcohol/Drug-Free Unit within the 30 days."
On August 30, 2012, six records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included an assessment of the client's composite picture, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and/or attitude toward treatment in six of six records reviewed, specifically, client records # 1, 2, 3, 4, 5, and 6. Also, the facility did not document a psychosocial evaluation according to their policy and procedures in one of six records reviewed, specifically, client record # 4.
Client # 1 was admitted on March 22, 2012. The psychosocial evaluation was completed on March 22, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 2 was admitted on March 19, 2012. The psychosocial evaluation was completed on March 20, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 3 was admitted on March 5, 2012. The psychosocial evaluation was completed on March 6, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 4 was admitted on March 26, 2012. The psychosocial evaluation was due April 25, 2012, but was not completed until May 2, 2012. Also, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 5 was admitted on May 18, 2012. The psychosocial evaluation was completed on May 23, 2012. However, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 6 was admitted on February 21, 2012. The psychosocial evaluation was completed on February 21, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
The findings were confirmed during an interview with the facility director on August 30, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on August 19, 2011; August 25, 2010; and September 21, 2009.
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Plan of Correction
The clinical supervisor will provide and in-service training session utilizing an evaluation identified during the review as meeting state guidelines with all of the clinical staff. The supervisor review and sign all evaluation to ensure that they meet policy guidelines. The clinical supervisor will focus supervision for the next 60 days on this area. Full compliance will be achieved by 10/30/12. The clinical supervisor will monitor for ongoing compliance on a monthly basis. |
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.
The findings include:
On August 30, 2012, seven 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 three of seven records reviewed, specifically, client records # 3, 6, and 7.
Client # 3 was admitted March 5, 2012. The individual treatment and rehabilitation plan was completed on April 3, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 30, 2012.
Client # 6 was admitted February 21, 2012. The individual treatment and rehabilitation plan was completed on March 21, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 30, 2012.
Client # 7 was admitted April 16, 2012. The individual treatment and rehabilitation plan was completed on April 16, 2012, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of August 30, 2012.
The findings were confirmed during an interview with the facility director on August 30, 2012 at approximately 3:00 P.M.
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Plan of Correction
The clinical supervisor will provide and in-service training session with all of the clinical staff on the documentation of the proposed type of support services in the individual treatment and rehabilitation plan. The supervisor review and sign all the individual treatment and rehabilitation plan to ensure that they meet policy guidelines. The clinical supervisor will focus supervision for the next 60 days on this area. Full compliance will be achieved by 10/30/12. The clinical supervisor will monitor for ongoing compliance on a monthly basis. |
711.94(b) LICENSURE Display Hours of Operation
711.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on observations on August 30, 2012, the facility failed to display the hours of project operation conspicuously to the general public.
The findings include:
A physical plant inspection was conducted on August 30, 2012. It was observed during the inspection at approximately 10:10 A.M., that the facility did not have the hours of project operation displayed conspicuously to the general public.
The findings were confirmed during an interview with the facility director on August 30, 2012 at approximately 10:10 A.M.
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Plan of Correction
As of 09-04-2012, the project operation hours were printed and displayed for the general public to read. The project operation hours will be posted at the front desk and the hallway bulletin board. The Clinical Supervisor will insure that the project operation hours are posted at the front desk and the hallway bulletin board by conducting monthly rounds. |
711.94(c) LICENSURE Display Emerg. Telephone Number
711.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on observations on August 30, 2012, the facility failed to display a telephone number for emergency purposes conspicuously displayed to the general public.
The findings include:
A physical plant inspection was conducted on August 30, 2012. It was observed during the inspection at approximately 10:10 A.M., that the facility did not have a telephone number for emergency purposes displayed conspicuously to the general public.
The findings were confirmed during an interview with the facility director on August 30, 2012 at approximately 10:10 A.M.
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Plan of Correction
As of 09-04-2012, the project's emergency phone number was printed and posted for the general public to read. The emergency phone number will be posted at the front desk and on the bulletin board. The Clinical Supervisor will insure that the project operation hours are posted at the front desk and bulletin board by conducting rounds. |