INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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 November 26, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records, the facility failed to document feedback on the completed training for the July 1, 2006 to June 30, 2007 training year in six of eight records reviewed, #1, 4, 9, 10, 14 and 15.
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Plan of Correction
Education Director will have staff complete feedback form and each form will be attached to each training certificate and placed in employee's file. The employees files will be reviewed quarterly (decemeber 12, 2007, march 12, 2008, June 12, 2008)by the education director and/or facility director. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual evaluation of the overall training plan that included a determination of the extent to which implementing the plan eliminated or satisfied the identified needs for the July 1, 2006 to June 30, 2007 training year.
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Plan of Correction
The Director will complete an annual evaluation report at the end of the training year. The report will be finished 01/25/08. The report will review trainings, feedback forms, and the direction of the program. |
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
Based on a review of training records, the facility failed to document a complete individual training plan that identified the subject areas and potential resources for training for the July 1, 2007 to June 30, 2008 training year in nine of fourteen client records reviewed, #4, 5, 6, 8, 9, 10, 12, 14 and 15
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Plan of Correction
Each staff member will develop an individual training program with director before the next training year begins (January 1, 2008). The Director will review all individual training plans quarterly to ensure that they have been completed timely and with all of the required information, including feedback forms, sign-in sheets, and descriptions of trainings. The training program will insure that at least 2 subject areas are covered each quater so that all areas will be addressed by the end of the training year. The training plan will also include any recurring mandatory trainings. For new employees, the subject areas will emphasize the development of a sound foundation for providing the treatment. |
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 training records, the facility failed to document 25 training hours in one of seven records reviewed, #14. Employee #14 received only 19.5 hours for the July 1, 2006 to June 30, 2007 training year.
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Plan of Correction
Each staff member will complete 25 hours of training based on annual training plan and monitored by the director. The 25 training hours will be earned for the July 2007 to June 2008 training year. The Director will monitor for compliance on a quartely basis and take necessary steps to enusre ongoing compliance. |
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 and training records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon employment in three of six records reviewed, #3, 5 and 6.
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Plan of Correction
All employees are instructed at the time of new employee orientation on the use of a fire extinguisher. This is included in the Fire Safety portion of the orientation. All employees sign off on receiving the education at this time. Employee numbers 3,5,and 6 will be re-educated by our safety officer before 12/31/2007 on the use of the fire extinguisher. Written proof of this education will be placed in the employees file. |
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 and training records, the facility failed to document that staff were trained to perform assigned tasks during emergencies in three of six records reviewed, #3, 5 and 6.
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Plan of Correction
Employees 3,5 and 6 will be re-educated with regard to their roles and assignments during an emergency. This will be completed by the safety officer prior to 12/31/2007. These employees will sign off that they have received this education and a copy will be placed in their employee file. This information will continued to be reviewed during the fire safety education at new employee orientation. Employees sign off that they received this education. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to document which exits were used during the fire drills for the past nine months.
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Plan of Correction
Every employee in the Tower building will be educated on the completion of the fire drill documentation. This education will be completed by each program director during their December staff meeting. This education will be completed by 12/31/2007. The education will include the importance of filling out the entire fire drill critique with special emphasis placed on the exit that was utilized during the fire drill. Quarterly reviews of the fire drill log will be conducted by the Director to ensure continued compliance. |
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a complete client personal history in seven of fifteen client records reviewed, #1, 2, 6, 9, 11, 20 and 21. The personal histories were missing or incomplete in the records reviewed.
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Plan of Correction
Director to conduct in-service with staff and review charts to ensure more thorough histories are completed. The in-service be held Monday, decemeber 19 2007. The topic will include how to gather history and engage client, the importance of filling out histories completely, and monitoring one's work. Client records be reviewed monthly by the director and lead counselors to ensure compliance. |
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 complete psychosocial evaluation in eight of fifteen client records reviewed, #2, 4, 6, 9, 11, 17, 20 and 21. Psychosocial evaluations did not include an assessment of the client's coping mechanisms and negative factors that may inhibit treatment or the psychosocial evaluations were missing entirely from the record.
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Plan of Correction
Director to perform in-service on completing pyschosocials on January 9, 2008. Specific goals of the in-service will be thhe topics of assessing the client's coping mechanisms and negative factors that may inhibit treatment. The lead counselors and director review records monthly to make sure psychosocial evaluation is complete and address coping skills and mechanisms. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the treatment plans in eleven of fifteen client records reviewed, #1, 3, 5, 6, 7, 9, 11, 17, 18, 19 and 20.
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Plan of Correction
Director and lead counselors to review charts to ensure completion of treatment plans every 60 days. Training will take place January 9, 2008 and focus on including an assessment on client's progress in relation to each goal. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide weekly individual treatment sessions as stated on the individual treatment and rehabilitation plan in six of fifteen client records reviewed, #1, 2, 3, 5, 6 and 7.
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Plan of Correction
Director to provide inservice on Jaunuary 12, 2008 on the relationship between weekly individuals sessions and treatment plans to ensure that recommendations are tailored to each client. In-service will includde proper documentation for missed seesions and treatment plan compliance. The lead counselors and Director will review records monthly to facilitate compliance. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of two client records reviewed, #16 and 25.
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Plan of Correction
Director too train staff to complete aftercare forms on January 9, 2008. Lead counselors to review client records to ensure compliance on a quarterly basis. |
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document a notice of termination in two of three client records reviewed, #13 and 24.
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Plan of Correction
Director to provide in-service on January 9, 2008 to staff on written communications that document termination of service. The training will indicate the proper manner in completing the notification of termination letter by staff and where a copy of the notification is to be maintained in the client record. The Director will review the client records for compliance quarterly. |