INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6-7, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System-Goldman Clinic 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Administrative documents were reviewed on September 4, 2018 through September 5, 2018. The facility failed to present the financial audit for fiscal year 2017.
The facility director confirmed the finding.
This is a repeat citation
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Plan of Correction
The CEO will request an exception to 709.25 based on NPHS recent Bankruptcy. The CEO will request the exception on December 1 , 2018 . Compliance with the financial audit requirement cannot be met until December 1, 2018
NPHS is in the process of filing back audits and 990 reports-if the exception is not granted audits will be available by December 2019. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of employee records, the facility failed to complete an annual written individual staff performance evaluation in three personnel records, #1, 3 and 16.
Employee #1 was hired 07/10/18.
Employee #3 was hired 05/08/17
Employe #16 was hired 03/10/14
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Plan of Correction
Employee # 1 ninety day probation period was not over at the time of inspection . Employee # 1 Date of Hire 7/11/18 probation will end on 10/11/18. Employee # 1 probation performance evaluation will be completed on or before 10/11/18 . Employee # 3 and 16 performance evaluation has been completed 10/1/2018 .All annual written individual staff evaluations will be reviewed and signed by supervisor and staff . Supervisors will review personnal files monthly to determine ,if a annual written performance evaluation is need on any employee. |
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 ten methadone client records the facility failed to document a valid consent to release information for clients #1-10. The facility's consent template states that the consent may only be revoked by notifying the facility's Medical Records Department.
Client #1 was admitted on 5/24/18 and was an active client at the time of the licensing inspection.
Client #2 was admitted on 7/13/18 and was an active client at the time of the licensing inspection.
Client #3 was admitted on 6/14/18 and was discharged on 8/2/18.
Client #4 was admitted on 6/20/18 and was an active client at the time of the licensing inspection.
Client #5 was admitted on 4/22/18 and was an active client at the time of the licensing inspection.
Client #6 was admitted on 6/21/12 and was an active client at the time of the licensing inspection.
Client #7 was admitted on 4/18/12 and was discharged on 3/29/18.
Client #8 was admitted on 2/27/18 and was discharged on 5/22/18.
Client #9 was admitted on 3/14/18 and was discharged on 6/5/18.
Client #10 was admitted on 12/7/17 and was discharged on 7/26/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will provide in-service training to all staff regarding the proper completion of consents, training will include all aspects of the consent .Clinical supervisors will begin conducting monthly audits during supervision to monitor counselors' ability to completed consents to ensure that active clients have valid consents in their records effective 11-1-2018. The three clinical supervisors will audit 72 charts each month . Clinical supervisors will provide increase supervision to counselors on completing consent forms to prevent recurrence.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Ten methadone client records were reviewed on September 6-7, 2018; the facility failed to document that the client was offered a copy of a consent to release information in client record 2 & 4.
Client #2 was admitted on 7/13/18 and was an active client at the time of the licensing inspection. One consent to release form for the client's emergency contact, two consents to release forms to a government agency and one consent to release form to another provider which were all dated July 13, 2018.
Client #4 was admitted on 6/20/18 and was an active client at the time of the licensing inspection. One consent to release form for the client's funding source, a consent to release to the contact and a consent to release form to a health care provider all dated June 21, 2018 and a consent to a treatment provider dated July 25, 2018.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
1.All facility staff will document the date a participant signed the consent forms. Staff will monitor and assist participants when needed with documenting date of their consent signing.
2.All facility staff will ensure that all consent forms fields are complete prior to transmitting information to an individual/or agency. All facility staff will document in progress notes related to consent forms process with participant.
3. All facility staff will at the time of a participant's annual evaluation review all consent forms. Consent forms needing updating will be review with participant for continuation of release of information and signature. New authorization for the release of information are signed by participant at their annual evaluation .
4.Clinical supervisor will review and monitor staff's ability to abide this correction action ,and 4 PA Code 255.5 and 42 CFR part 2 during monthly supervision.
5. A in-service on 4 PA Code 255.5 and 42 CFR part 2 will be performed on 10/29/2018
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's significant incident reports revealed that the facility failed to report to the Department, the death of two clients. The first report reviewed was 2/19/18 and the other was dated 8/10/18.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Unusual Incident report 715.28 will be revised to reflect Department of Health 's time frame of 72. hrs. The facility will submit unusual incident reports within 72 hour or before. Supervisor will review revised policy with front line staff during treatment team meeting 10/29/2018.Supervisors will monitor compliance to Policy |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
A review of the facility's Significant Incident Reports revealed that the facility failed to report, to the Department, events that required the presence of police, fire or ambulance personnel.
Six of the report reviewed verified that rescue personnel were called to the facility on the following dates:
02/01/18
02/26/18
03/21/18
08/02/18 for two separate incidents
08/09/18
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will review the current policy to identify the 5 unusual incidents that require an unusual incident report form to be sent to the Department of Health within 72 hours as per standard 715.28(c)(1-5). The Program Director will provide staff training and review to the supervisors and counselors by 11/01/2018. The training will detail that when one of these 5 incidents occur, an unusual
incident report will be filed with the Department and a copy will be given to the Program Director. This correspondance will be placed in the unusual incident binder. This will begin on 11/1/2018.The facility will report all unusual incidents to the Department.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to keep the grounds free from any danger to health and safety.
The ground exit from the east fire tower had cracks in the sidewalk and a fence that was damaged which allows access to a ledge leading to a subterranean 'pit'. Additionally, an exit door, located on the second floor had a window with a hole in the glass with jagged edges presenting a safety hazard.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
IS3 (Ironstone) the Landlord will completed repair of the exit, area and the broken window. Maintenance staff will perform daily ground tours to detect any health and safety issues and prevent recurrences . Goldman administration will sent in work orders related to any health and safety to Ironstone in a timely manner to ensure this deficiency does not recur .
Responsible Party: IS3 Maintenance Department Date of Completion: 10-25-18
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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.
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Observations
Based on the physical plant inspection the facility failed to keep the grounds free from any danger to health and safety.
An empoyee kitchen located on the 2nd floor near the restroom had rodent droppings in the cabinets and along the wall.
Additionally, there was black mold observed on the ceiling tile located in the 2nd floor group room.
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
IS3 Ironstone keep the grounds free from any danger to health and safety.IS3 Ironstone will keep cabinets free of rodent droppings in the building.Maintenance staff will perform daily ground tours to detect any health and safety issues and prevent recurrences . Goldman administration will sent in work orders related to any health and safety to Ironstone in a timely manner to ensure this deficiency does not recur .
Responsible Party: IS3 Maintenance Department Date of Completion: 10-25-2018
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on the physical plant inspection the facility failed to provide all of the required elements in each bathroom.
The staff bathroom located on the 1st floor did not have any paper towels or a mechanical dryer.
The client bathroom located on the 1st floor in the cafeteria did not have a mirror, soap dispenser, paper towels or a mechanical dryer.
The findings was dicuss with facility staff during the licensing inspection.
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Plan of Correction
The Sr. Vice President will review the housekeeping performance guidelines with the Director of Housekeeping regarding cleaning and stocking bathrooms-Responsible Party SrVP-Completion October 1, 2018
Support staff will monitor bathrooms during daily environmental rounds to insure paper products are available and will report any problems immediately to the housekeeping department.
Responsible Party-ARA's MHW's and CRS?Ongoing Monitoring-Date of completion 12-31-18
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to prohibit heaters that are not permanently mounted or installed.
There were portable heaters in the following offices:
Medical office in the administrative area on the 1st floor.
Counselor's office next to Group Room A on the 2nd floor.
Counselor's office #471 on the 4th floor.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The space heaters were immediately be removed from premises. The staff members will be reminded of regulations regarding space heaters . The clinical supervisors will monitor compliance with this regulation on an going basis. Maintenance department will be contacted , if there are any heating or cooling problems . |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of the physician's and physician assistant's schedules and the daily patient census, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
The period reviewed: April 1, 2018 through August 18, 2018. The facility was not in compliance for the following weeks:
April 22-28, 2018: patient census 550, required 55.0 hours; documented coverage 53.45 hours.
July 15-21, 2018: patient census 552, required 55.2 hours; documented coverage 40 hours.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director and office manager will review the physician monthly schedule to ensure program coverage . The facility will provide on-site physician coverage of one hour per week for every ten participants in program . Director,office manager and medical director will be responsible for reviewing the physician's schedule.Director will monitor and coordinate physician hours to provide participant coverage based on census. Director will request addition physician coverage from administration , due to vacations or any other the reason that might affect medical staffing . |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Ten methadone client records were reviewed on September 6-7, 2018, the facility failed to document monthly urine screens in client record, #9.
Client #9 was admitted on 3/14/18 and was discharged on 6/5/18. There was an initial urine screen documented on 03/14/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The office manager or billing clerk will print out daily a randomized list of participant to perform urine sample from Avatar system . The daily listing for urine samples will be provide to check-in clerk . Participant(s) will provide urine sample as upon request. If a participant is not comply a clinical supervisor will be contacted . Counselor will review urine samples with participant during sessions and document results . Goldman Clinic participant are required to submit at least one random monitored urine per month. Participants are monitored by Nursing Staff via a monitor and security video camera located in the participant's restroom. Nursing Staff or Clinical Staff may request participant a breathalyzer exam, if necessary, before being medicated.Clinical supervisors monitor UDS monthly when they are doing their client file audits to ensure they are being done monthly. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Ten methadone client records were reviewed on September 6-7, 2018, the facility failed to document that the required information was sent to the receiving methadone facility.
Client #1 was transferred into the facility on 5/24/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All documents required for transfer by standard 715.20(1) will be document and scanned into chart . This procedure was reviewed with the counseling staff by the supervisors on 10/15/2018 and the process is to begin immediately. Supervisors will provide oversight of this procedure. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Ten methadone client records were reviewed on September 6-7, 2018, the facility failed to document a discharge summary in client record #8.
Client #8 was admitted on 2/27/18 and was discharged on 5/22/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisors will perform a in-service on completing discharge process as per policy 709.91 (a)(4) . The facility will ensure that discharge summaries will be document by performing a in-service on the procedure 11/1/2018 by supervisors during team meeting.Clinical supervisors will begin conducting monthly audits during supervision to monitor counselors' ability to file. The three clinical supervisors will audit 72 charts each month . Clinical supervisors will provide increase supervision to counselors on filing discharge summaries to prevent recurrence. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Ten methadone client records were reviewed on September 06-07, 2018. The facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluation statement and recommendations in records, #1-3, & 8-10.
Psychosocial evaluation for client #1 was documented on 5/24/18.
Psychosocial evaluation for client #2 was documented on 7/17/18.
Psychosocial evaluation for client #3 was documented on 6/18/18.
Psychosocial evaluation for client #8 was documented on 2/27/18
Psychosocial evaluation for client #9 was documented on 3/15/18
Psychosocial evaluation for client #10 was documented on 12/07/17
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisors will review Policy; Intake assessment procedures and level of care 715.9( A-4) during treatment team meeting focusing on (d) the counselor completes the Psychosocial History and Psychosocial Evaluation within the first (30) days of admission and developing a list of problems to be reported in the Comprehensive Treatment plan on 10/29/2018. Supervisor will perform chart audits monthly focusing on the completion of the clinical impressions portion of the assessment. The three clinical supervisors will audit 72 charts each month. Clinical supervisors will provide increase supervision to counselors on completing and documenting psychosocial evaluations , statement to prevent recurrence. A focus review will be conducted for 90 days. |
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 a review of client records, the facility failed to update treatment plans every 60 days for client records #4 & #10.
Client #4 was admitted on 6/20/18 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was documented on 7/3/18; a treatment plan update was due by 9/3/18 but was not documented at the time of the inspection.
Client #10 was admitted on 12/7/17 and was discharged on 7/26/18. A comprehensive treatment plan was documented on 3/21/18; a treatment plan update was due by 5/21/18 but was not documented until 5/23/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisors will review Policy Management of treatment/Rehab services 709.92(3)focusing (8) Treatment Plan Update- the counselor completes the update treatment plan every sixty days following the comprehensive treatment plan during treatment team meeting on 10/29/2018.Assigned counselor completed updated treatment on 9-11-18 on client 4 #MM. Supervisors will conduct chart audits to verify compliance monthly. Supervisors will report non-compliance to Director during supervision. Supervisors will conduct a 90 day focused review beginning November 15, 2018. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
A review of the Staffing Requirement Facility Summary Report indicated that the facility failed to complete an annual individual training plan for three staff members. Annual training plans were not completed for employees #19, #20 and #21.
Employee #19 was hired 8/09/99.
Employee #20 was hired 8/07/08.
Employee #21 was hired 5/14/12.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will create a check sheet identifying all staff and monitor that Training plans are completed within 30 days of hire for new employees and by January 31, of each year for all other employees.
Employee #19 are security staff , Director will notify medical records director about need to complete annual training plans on 11/1/2018 and follow -up.Employee #20 and # 21 are security staff , Director will notify security director about need to complete annual training plans on 11/1/2018 and follow -up
Responsible?Clinical Supervisor - Date of completion ---11-1-18 |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of the facility's personnel records, the facility failed to show documentation that all staff completed the communicable disease trainings within the required timeframe.
Employee #1 was hired as a counselor on 07/10/17. The HIV/AIDS training was due to be completed by 07/10/18 but was not documented at the time of the inspection.
Employee #19 was hired as a support staff person on 08/09/99. This employee's personnel record did not have documentation of the HIV/AIDS or the TB/STD trainings as of the date of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Two personnel records were reviewed during survey . The two employee were missing required training . Employee#1 will be scheduled for HIV/AIDS training 11/15/2018. Employee# 19 will be scheduled for next HIV /AIDS and TB/STD by 11/15/2018. Clinical supervisors will conduct a quarterly personnel file review for training hours compliance. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the facility's personnel records, the facility failed to ensure that the facility director completed at least 12 clock hours of training annually.
Employee #14 was hired as the facility director on May 14, 2012. Training certificates were reviewed for the period from January 1, 2017 through December 31, 2017; Employee #14 had documented only 0.5 hours of trainings at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor(s) will meet with employees during supervision and treatments teem meetings and reinforce importance of obtaining 25 education clock annually by 10/29/2019
* The Director and the Clinical Supervisors will schedule and monitor all trainings to ensure compliance.
* Clinical Supervisor will conduct quarterly reviews of the counselor's training plans to ensure hours are being met. All complete trainings will require a certificate of attendance with the date and hours of training. The counselor will complete a training evaluation to submit with the certificate.
*Facility Director is responsible for attaining all required hours and filing academic transcript
*Facility Director will ensure academic credits are document in personal file
* Facility Director will contact academic facility after completing each semesters.
*Vice President of behavior health will oversee and ensure that facility director has all required training hours
Full compliance will be achieved 12-31-2018.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the facility's personnel records, the facility failed to ensure that counselors completed at least 25 clock hours of training annually.
Training certificates were reviewed for the period from January 1, 2017 through December 31, 2017.
Employee #16, a counselor hired on 03/10/14, completed 16.5 hours of the required 25 hours for the annual training period.
Employee #17, a counselor hired on 12/29/10, completed 19.5 hours of the required 25 hours for the annual training period.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor(s) will meet with employees during supervision and treatments teem meetings and reinforce importance of obtaining 25 education clock annually by 10/29/2018
* The Director and the Clinical Supervisors will schedule and monitor all trainings to ensure compliance.
* Clinical Supervisor will conduct quarterly reviews of the counselor's training plans to ensure hours are being met. All complete trainings will require a certificate of attendance with the date and hours of training. The counselor will complete a training evaluation to submit with the certificate
*Effective 11-1-2018 , quarterly reviews of counselors training plans will begin.
Full compliance will be achieved 12-31-2018. |