INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 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, Return Program 1 & 2, 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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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 personnel records revealed that the facility failed to complete an annual individual training plan for one staff member. An annual training plan was not completed for employee #6.
Employee #3 was hired on 10/1/13.
The findings was reviewed with 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 Responsible?Clinical Supervisor - Date of completion ---11-1-18
the facility will have an annual training plan completed for employee # 6 on 11/15/18
responsible: clinical supervisor
date of completion 11/15/18 |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
The facility failed to maintain counseling areas with furnishings which are in good repair.
Couches located in 3 west lounge were in poor condition with rips and large sections of fabric missing at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
the director of residential services will order new cushion and couch covers for the program.
responsible person: clinical director
completion date 11/30/18
to ensure that his does not occur again the clinical supervisors will report the need of any furniture repair during the monthly clinical supervisors meeting. the clinical supervisor will conduct a weekly walk through of the program
responsible person: Clinical supervisor
completion date :11/30/2018 |
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. Compliance with the financial audit requirement cannot be met until December 2019
expected date of exception request 12/1/2018
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.
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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
A review of seven client treatment records revealed that the facility failed to obtain a valid consent to release form from the client for the disclosure of information contained in the client record.
Client #1's file contained a general consent dated 7/31/18 that didn't indicate the recipient of the information to be released. Another consent to a funding agency dated 7/31/18 that did not specify the purpose of the disclosure. In addition, a general consent dated 7/31/18 did not specify the purpose of the disclosure. Lastly, a consent to release information to a government agency and a consent to release information to a funding source, both dated 7/31/18, that did not have an acknowledgment that the client was offered a copy of the consent.
Client #2's file contained a general consent dated 7/10/18 that didn't indicate the recipient of the information to be released. Another consent dated 7/10/18 that did not specify the purpose of the disclosure. In addition, a consent to a government agency dated 07/10/18 did not specify the purpose of the disclosure. Lastly, a consent to release information to the funding source and a consent to release information to a government agency, both dated 7/10/18, that did not have an acknowledgment that the client was offered a copy of the consent.
Client #3's file contained a general consent dated 5/09/18 that didn't indicate the recipient of the information to be released. Another consent dated 05/09/18 that did not specify the purpose of the disclosure. Lastly, a consent to release information to the funding source and a general consent to release information,both dated 5/09/18 that did not have an acknowledgment that the client was offered a copy of the consent.
Client #4's file contained a consent to probation and parole dated 3/26/18 that did not specify the purpose of the disclosure.
Client #6's file contained a general consent dated 7/10/18 that didn't indicate the recipient of the released information. Another consent to release to the funding source dated 7/10/18 that did not have an acknowledgment that the client was offered a copy of the consent.
Client #7's file contained a general consent dated 04/24/18 that did not specify the purpose of the disclosure. Another consent to release to the funding source and a general consent to release information, both dated 4/24/18, did not have an acknowledgment that the client was offered a copy of the consent.
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 conduct Random monitor of three (3) charts per clinician per month to validate that consents forms are completed correctly
Responsible Party: Clinical Supervisor Completion Date 1/15/19
the staff training will be held December 13,2018
the review of client records will begin on 11/14/2018 |