INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Philadelphia Health Management Corporation/Chances was found to be not 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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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential 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 a physical plant inspection conducted on October 26, 2016, the facility failed to provide a operational soap dispenser in the lower-level restroom.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director was unaware of the inoperable soap dispenser in the lower level bathroom. Since the inspection there has been soap available and an operational soap dispenser in all of the bathrooms including the lower level.
The cleaning technician will check 3 times weekly to ensure that there is available soap and an operational dispenser. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and a conversation with the facility staff, the facility failed to conduct fire extinguisher training upon hire in records, #3, 4, 5, 6, 7, 8, 9 & 10.
Employee #3 was hired on 11/23/2015. Fire extinguisher training was documented on 6/16/2016.
Employee #4 was hired on 4/4/16. Fire extinguisher training was documented on 10/7/2016.
Employee #5 was hired on 5/19/16. Fire extinguisher training was documented on 10/7/2016.
Employee #6 was hired on 5/9/16. Fire extinguisher training was documented on 10/7/2016.
Employee #7 was hired on 9/8/16. Fire extinguisher training was documented on 10/17/2016.
Employee #8 was hired on 9/8/16. Fire extinguisher training was not documented as of the date of the inspection.
Employee #9 was hired on 9/22/16. Fire extinguisher training was documented on 10/7/2016.
Employee #10 was hired on 9/12/16. Fire extinguisher training was documented on 10/19/2016.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Fire extinguisher training will be included as part of the new hire process and will be incorporated in the initial orientation of new hire staff.
The fire extinguisher training will occur within the first three days of hire. This will be monitored by the Program Director and Human Resources. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a conversation with the facility staff, the facility failed to conduct emergency training upon hire in records, #3, 4, 5, 6, 7, 8, 9 & 10.
Employee #3 was hired on 11/23/2015. Employee training for emergencies was documented on 6/16/2016.
Employee #4 was hired on 4/4/16. Employee training for emergencies was documented on 6/16/2016.
Employee #5 was hired on 5/19/16. Employee training for emergencies was documented on 10/7/2016.
Employee #6 was hired on 5/9/16. Employee training for emergencies was documented on 10/7/2016.
Employee #7 was hired on 9/8/16. Employee training for emergencies was documented on 10/17/2016.
Employee #8 was hired on 9/8/16. Employee training for emergencies was not documented as of the date of the inspection.
Employee #9 was hired on 9/22/16. Employee training for emergencies was documented on 10/7/2016.
Employee #10 was hired on 9/12/16. Employee training for emergencies was documented on 10/19/2016.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee trainings for emergencies will be conducted as part of the new hire orientation training on date of hire at work site.
This will be monitored by the Program Director and Human Resources to ensure that all new hire employees receive emergency training on the date of hire. |
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 personnel records and a conversation with the facility staff, the facility failed to document an annual work performance evaluation for employee #2.
Employee #2 was hired on 8/1/2005. The last annual evaluation was documented on 7/1/2015.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Program Director will ensure that all annual employee performance evaluations are done annually and in a timely manner.
The annual evaluation will be completed by 12/16/2016.
This will be monitored by the Program Director and Human Resources. |
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 and a conversation with the facility staff, the facility failed to document an informed and voluntary consent in client records, #3 & 8.
Client #3 was admitted on 1/27/16 and was an active client at the time of the licensing inspection. According to the Facility Director client #3 was funded through Medical Assistance and the record contained an insurance identification card, however there was no consent form to any funding source documented in the record.
Client #8 was admitted on 10/15/15 and was discharged on 3/7/16. According to the Facility Director client #8 was funded through Medical Assistance, however there was no consent form to any funding source documented in the record.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
During our treatment intake process, all newly admitted participants complete release forms for our funders. Due to our oversight with Charts #3 and #8, we will research each participant chart per assigned therapist to ensure that all consents are present and complete.
Completion date 12/30/2016.
We will also facilitate a discussion with our intake team of the importance of reviewing all intake forms for correction and completion before submission for supervisors signatures.
Completion date 12/12/2016.
This will be monitored by the Clinical Director. |
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 on a review of client records, the facility failed to document an update of the treatment and rehabilitation plan in client records #2, 3, 4 & 7.
Client #2 was admitted on 5/7/16 and was an active client at the time of the licensing inspection. Client record #2 contained a comprehensive treatment plan dated 5/20/16; a treatment and rehabilitation plan update was due by 7/20/16 however the update was not completed until 8/17/16.
Client #3 was admitted on 1/27/16 and was an active client at the time of the licensing inspection. Client record #3 contained a treatment and rehabilitation plan update dated 8/19/16. Another review and update of the treatment and rehabilitation plan was due by 10/18/16 however the update was not completed until 10/20/16.
Client #4 was admitted on 1/29/16 and was an active client at the time of the licensing inspection. Client record #4 contained a treatment and rehabilitation plan update dated 8/19/16. Another review and update of the treatment and rehabilitation plan was due by 10/18/16 however the update was not completed until 10/20/16.
Client #7 was admitted on 8/6/15 and was discharged on 1/19/16. Client record #7 contained a treatment and rehabilitation plan update dated 11/13/15. Another review and update of the treatment and rehabilitation plan was due by 1/12/16 however the update was not documented in the client chart as of the date of the licensing inspection.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program will implement a new procedure for Treatment Plan Updates in order to ensure that Treatment Plan Updates are completed at least every 60 days. All clinicians will complete treatment plan update reviews and submit to supervisors for supervisor and physician review at least 14 days before the the Treatment Plan update is due. Supervisors and Physicians will review and sign completed plans before the due date. Staff was informed of these changes during our December 2016 clinical team meeting. The new procedure is effective immediately following the meeting. Completion Date 12/8/2016. This will be monitored by the Clinical Director. |