INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-15, 2008 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 and a plan of correction is due on September 24, 2008.
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Plan of Correction
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records on August 20, 2008, the facility failed to conduct fire drills on a monthly basis.
Findings:
There was no documentation of a fire drill for July 2008.
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Plan of Correction
A mandatory in-service was held on Monday, August 25, 2008 at 10am. The Fire Marshall conducted the education. All managers from the Tower building were required to attend. A review was completed with regard to the proper process for completing fire drill documentation. A new process was implemented which requires all fire drill documentation from the unit to be submitted to the CEO within 24 hours of the drill. All documentation will be reviewed for content and completeness by the CEO. Any documentation that is incomplete or needs to have content revision will result in the calling of the manager of the unit to assure correction. This will start immediately. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records on August 20, 2008, the facility failed to document that alternate exit routes were used during fire drills.
Findings:
There was no documentation of alternate exit routes in the monthly fire drill logs from November 2007 through June 2008.
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Plan of Correction
Mandatory Fire Education was conducted by the Fire Marshall for the Tower Managers on August 25, 2008 at 10am. One agenda item of this education provided a review of the use of the alternate fire tower as an exit during fire drills. The Fire Marshall will provide education to each Tower unit manager which will include the physical walk down the fire tower to make all managers familiar with the route prior to the actual drill taking place. By December 1, 2008, all units will have completed their education on utilizing the alternate fire tower during a fire drill and a fire drill will be conducting utilizing this alternate route. Appropriate documentation of the use of this exit will be completed and sent to the CEO for review and be placed in the Fire Drill Log binder. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of three client records on August 14, 2008, all three were required to have psychosocial evaluations. The facility failed to document complete psychosocial evaluations in two of three client records where required.
Findings:
Psychosocial evaluations documented in client records # 2 and 3 were a repeat of historical data and did not include a clinical assessment of how the client's assets/strengths, support systems and negative factors may impact the current treatment and recovery effort. potential for treatment. Additionally, the handwritten psychosocial evaluation for client record #1 was illegible.
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Plan of Correction
Additional inservice training will be provided by the staff development department by October 31, 2008 on psyhcosocial evaluations. Staff will recieve additional supervison focused on this area by the clinical supervisor and Program Director over the next sixty days.Chart audits will be completed on a monthly basis by the clinincal supervision and program director to ensure that the deficiency does not reoccur. A corrective action plan including computer training has been developed for the staff member whose handwriting was illegible. The anticipate completion of his training is 10-31-08. |
711.52(c)(1) LICENSURE Treatment goals
711.52. 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:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of three client records on August 14, 2008, three were required to have comprehensive treatment plans.
Finding:
The facility failed to document treatment plan goals stated in terms of measurable criteria in two of three client records reviewed, #1 and 2.
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Plan of Correction
Additional training on treatment planning will be provided by the Staff Development on or before October 31, 2008. Staff will be provided copies of the Addiction Treatment Planner as resource for writing measurable treatment plans and the clinincal supervisor will provide monthly review on and ongoing basis. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of three client records on August 14, 2008, all three were required to have treatment plan updates. The facility failed to document a complete treatment plan update in two of three client records where required.
Findings:
Treatment plan updates were missing an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records #1 and 2.
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Plan of Correction
Staff will recieved additional training on treatment planning by October 31, 2008. Training will be conducted by the staff development department and the Chief of Residential Services. The clinical supervisor will monitor treatment plans on a monthly basis to ensure that they include an assessment of the progress of stated goals. Increased monitoring will begin immediately. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) 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 three client records on August 14, 2008, the facility failed to obtain an informed and voluntary consent from the client in three of three client records where required.
Findings:
The Consent to Treatment Form specified that the client's consent to release information was not required for homicidal or suicidal ideation. Additionally, consents to release information signed by clients did not include the clients' right to verbally revoke a consent to release information. The information was missing from client records # 1, 2 and 3.
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Plan of Correction
The Confidentiality information section of the Consent for Treatment will be revised. This revision will be conducted by the Director of Residential Services, The VP of Behavioral Medicien, and the Director of Patient/Client Access. This will be completed by 9/30/2008. Two items will be added to the consent:
1. you have the right to verbally revoke consent to release information.
2. a court order is needed to divulge information without consent for clients expressing suicidal or homicidal ideation and/or intent. |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Based on a review of three client records on August 14, 2008, the facility failed to obtain an informed and voluntary consent from the client in two of three client records reviewed.
Findings:
The specific information to be released to the Office of Medical Assistance [ a government entity and a third party payer], that was listed on consent to release information forms in client records # 1 and 2, exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b). The information listed for release included case consultations.
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Plan of Correction
Staff will recieve inservice training from the Program Director regarding the use of release of information forms. The pre-printed consent for the Department of Public Welfare confirms with 4 Pa. Code subsection 255.5(b). The inservice will be completed by 9/15/08 . Chart reviews will be completed on a weekly basis by the addiction recovery assistant or the mental health worker to ensure that the deficiency does not reoccur. |