INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff as it pertains to confidentiality and the release of information, which includes process for completing and obtaining signatures of the release of information and consent form by June 18, 2021. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. Clinical supervisor will review all active clients and ensure that ROI have been completed and signed by June 30, 2021. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in four of seven client records reviewed.
Client #1 was admitted on February 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff as it pertains to notifying clients of their right obtaining signatures of the release of information and consent form by June 18, 2021. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. Clinical supervisor will review all active clients and ensure that client rights have been completed and signed by June 30, 2021. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in four of seven client records reviewed.
Client #1 was admitted on February 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff as it pertains to obtaining written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services by June 18, 2021. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. Clinical supervisor will review all active clients and ensure that client rights have been completed and signed by June 30, 2021. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to inspect their own records, that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and that reasons for removing sections shall be documented in the record in four of seven client records reviewed.
Client #1 was admitted on February 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff as it pertains to clients rights to inspect their own records as well as the project, facility, or clinical director right to temporarily remove portions of the records prior to inspection if deemed detrimental to client. Clinical supervisor will review policy on ensuring that all required signatures are obtained for the release of information and consent forms by June 18, 2021. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. Clinical supervisor will review all active clients and ensure that client rights have been completed and signed by June 30, 2021. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in four of seven client records reviewed.
Client #1 was admitted on February 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff by June 18, 2021, as it pertains to ensuring that written acknowledgement is received from clients indicating that they have been notified of their right to appeal a decision limiting access to their records and the process by which to appeal. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. Clinical supervisor will review all active clients and ensure that client rights have been completed and signed by June 30, 2021. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in four of seven client records reviewed.
Client #1 was admitted on February 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff by June 18, 2021, as it pertains to obtaining written acknowledgement by client that they have been notified of their right to request correction of inaccurate, irrelevant, outdate, or incomplete information in their record. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. Clinical supervisor will review all active clients and ensure that client rights have been completed and signed by June 30, 2021. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
Client #1 was admitted on February 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff by June 18, 2021, as it pertains to obtaining written acknowledgement by client that they have been notified of their right to submit rebuttal or memoranda to their own record and the process by which to do so. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. Clinical supervisor will review all active clients and ensure that client rights have been completed and signed by June 30, 2021. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project during intake in three of five client records reviewed.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no client orientation documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no client orientation documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no client orientation documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff by June 18, 2021, as it pertains to client orientation to program at the time of intake and obtaining written acknowledgement. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment during intake in three of five client records reviewed.
Client # 2 was admitted on January 19, 2021 and was still active at the time of the inspection. There was no consent to treatment documented in the record at the time of the inspection.
Client # 3 was admitted on February 17, 2021 and was still active at the time of the inspection. There was no consent to treatment documented in the record at the time of the inspection.
Client # 5 was admitted on January 27, 2021 and was discharged on April 6, 2021. There was no consent to treatment documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review policy and procedure with staff by June 18, 2021, as it pertains to reviewing, completing, and obtaining written acknowledgement of consent for treatment. In addition, effective June 14, 2021, clinical supervisor will complete monthly audit to ensure that all new admissions have been provided and oriented on the consents and release information. |