INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16-17, 2015 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 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by use of an exhaust fan or window.
The findings include:
A physical plant inspection was conducted on September 17, 2015. The facility failed to ventilate the bathroom in the daycare by exhaust fan or window.
The mechanical exhaust fan in the daycare was not operable at the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Chances Program notified property management, Regis Development on 9/21/2015 of inoperable exhaust fans in daycare. The property management maintenance person came out and repaired the exhaust fans as of 9/23/2015.
The childcare staff will perform weekly inspections of the daycare bathrooms to ensure all fans are working and bathrooms remain ventilated. Staff and program director will monitor compliance on a monthly basis. |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on September 17, 2015. The facility failed to keep frozen food at or below 0 degrees Fahrenheit.
The freezer temperature was 5 degrees at the time of inspection. In addition, the freezer temperature log for the month of September 2015 documented 5 degrees on September 9, 14, 15 and 16. The facility failed to document the freezer temperature on September 2, 4, 7, 8, 10 and 11.
The freezer temperature log also incorrectly documents the freezer temperature range as " 0-5 degrees for freezer. "
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Sears Appliance Repair has been contacted to come service and inspect the freezer to ensure that the freezer is working properly and the temperature will maintain at zero or below temperature reading. This inspection and service will occur by 11/30/2015. This service and inspection will happen to correct deficiency.
The kitchen coordinator/cook will ensure that the temperature for the freezer will read zero or below at all times. The unit will be inspected quarterly to ensure the freezer is in good working order. The kitchen coordinator and respective staff will be informed of the thermometers location and how to properly document the temperature readings in the log book.
The kitchen coordinator/cook will inspect the unit daily and record temperature as required for this regulation,705.25 The program director will monitor the log book temperature entries on a monthly basis. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of one operable automatic smoke detector on each floor, including the basement.
The findings include:
A physical plant inspection was conducted on September 17, 2015. The facility failed to maintain a minimum of one operable automatic smoke detector on each floor, including the basement.
At the time of inspection, the facility did not have a smoke detector in the basement.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/17/2015 building property management, Regis Development was notified regarding smoke detectors needed on the basement level. Regis development responded on 9/17/2015 and installed two smoke detectors on the basement level of the Chances Program. Chances will remain in compliance with fire safety regulation 705.28 by ensuring operable automatic functioning smoke detectors are located in designated areas including the basement level.
The office manager will inspect that all smoke detectors are properly functioning and operable on a monthly basis. The program director will monitor compliance with this regulation on a monthly basis. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Confidentiality
Based on a physical plant inspection, the facility failed to maintain the confidentiality of client identity.
The findings include:
A physical plant inspection was conducted on September 16 - 17, 2015. The facility failed to maintain the confidentiality of client identity by allowing the client sign-in sheet to be located at the front desk in the waiting area. The clients would sign their first and last name on the sign-in sheet that can be seen by anyone coming to the front desk.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
On 9/16/2015 Chances had a sign in sheet at the front desk waiting area which presented both first and last names of participants. As of 9/18/2015 the sign in sheet at the front desk has been replaced and only reflects the first name and last initial of participants in the program.
The administrative assistant will ensure that the sign in sheet reflects first name and lsst initial when participants sign in and uphold confidentiality compliance of participant identity at the front desk sign in sheet. The program director will monitor the confidentiality of participants identity is upheld on the sign in sheet on a weekly basis. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six of eleven records reviewed.
The findings include:
Eleven client records were reviewed on September 16 - 17, 2015, to ensure that the facility obtained an informed and voluntary consent from the client for the disclosure of information. The facility failed to obtain an informed and voluntary consent in client record, # 1, 3 4, 9 10 and 11.
Client # 1 was admitted to the facility on June 11, 2015. The facility obtained a consent to release from client # 1 on June 11, 2015 that did not comply with 4 Pa. Code 255.5. The facility documented the disclosure of client # 1 ' s UDS results to probation and parole.
Client # 3 was admitted to the facility on May 19, 2015. The facility obtained consent to release from client # 3 on May 19, 2015 that did not comply with 4 Pa. Code 255.5. The facility documented the disclosure of client # 3 ' s UDS results to probation and parole and FIR. In addition, a review of DAP progress notes on 7/17/15 and 6/19/15 documented " therapist completed FIR weekly provider report, which indicates participant ' s attendance, UDS screening results, as well as admission and discharge information. "
Client # 4 was admitted to the facility on April 13, 2015. The facility obtained consent to release from client # 4 on May 22, 2015 that did not comply with 4 Pa. Code 255.5. The facility documented the disclosure of client # 4 ' s UDS results to a governmental entity.
Client # 9 was admitted to the facility on February 6, 2015. The facility failed to obtain consent to release from client # 9 for the disclosure of information to an outside treatment provider. On July 24, 2015, the facility documented on a progress note, "spoke with worker regarding client." The worker in question was the outside treatment provider that the facility failed to have a consent to release on file in client record #9.
Client # 10 was admitted to the facility on November 3, 2014. The facility failed to obtain a valid consent to release from client # 10. On February 3, 2015, client # 10 signed a general consent to release to probation and parole which documented the disclosure of, "name, clinically specific information, and anything currently going on."
During the review of client #11's supplemental record the facility failed to obtain a valid consent to release. On July 27, 2015, client # 11 signed a consent to release that did not comply with 4 Pa. Code 255.5, as the facility documented the release of client # 11's UDS results to DHS.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Chances clinical staff received Confidentiality training on 10/26/15 and childcare staff received it on 10/29/2015.The clinical director will provide a mandatory training to all other staff to address client privacy, voluntary consents,release of information and 255.5 This training will be held by 12/3/15. .
Effective immediately, all consents will be in writing and will include (1) name of person, agency or organization to who disclosure is being made to (2) specific information being released (3) purpose of disclosure (4) dated signature of participant (5) dates signature of witness(6) date consent expires. Effective immediately, all active clients will be asked to complete consent to release forms at intake. If releases are needed beyond intake they will be requested by the therapist. For paricipants that are active and out of compliance the therapist will have them sign appropriate releases during their next therapy session in order to be compliant with 255.5
The clinical director and TQM team will perform monthly chart audits to ensure voluntary release of information forms are obtained as needed, completed accurately and comply with 255.5.
Program director will monitor compliance via monthly supervisions and chart audit reports.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff 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 notify the client in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two client records.
The findings include:
Two client records requiring documentation of notification of termination were reviewed on September 16 - 17, 2015. The facility failed to provide notification of termination in one of two records reviewed, specifically client record # 9.
Client # 9 was admitted to the facility on February 6, 2015 and was involuntarily terminated on July 27, 2015. The facility failed to provide client # 9 with notification of termination as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program director will revise the policy that describes the documentation requirements for involuntary discharges. The Program director will also develop a formal letter that will be mailed to participants to provide them with written notification of their discharge and termination of services. The letter will include instructions on how to appeal the decision of involuntary termination along with the procedures for re-admission should the participant decide to return at a later date. The program director will review this policy with the program staff on 11/19/15.
Compliance with this policy will be reviewed on a quarterly basis by clinical director and TQM team. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to comply with 55 Pa. Code Part III relating to the Medical Assistance Manual in five of ten records.
The findings include:
Ten client records were reviewed on September 16 - 17, 2015, to ensure the facility complied with 55 Pa. Code Part III (relating to Medical Assistance Manual.) The facility failed to ensure the physician signed treatment plans as required by 55 Pa. Code Part III Chapter 1223 Outpatient Drug and Alcohol Clinic Services 1223.52; in client record # 1, 2, 6, 7 and 9.
Chapter 1223 Outpatient Drug and Alcohol Clinic Services
(i) Within 15 days following intake, the clinic ' s supervisory physician shall review and verify each patient ' s level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic ' s supervisory physician shall verify the patient ' s diagnosis. The clinic ' s supervisory physician shall sign and date the patient ' s level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient ' s record. Payment will not be made for services provided within or beyond the 15th day following intake, without the clinic ' s supervisory physician ' s review and approval of the level of care assessment, psychosocial evaluation, treatment plan and determination of the patient ' s diagnosis.
(ii) Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic ' s supervisory physician shall review and update each patient ' s treatment plan. Each review and update shall be dated, documented and signed in the patient ' s record by the clinic ' s supervisory physician.
Client # 1 was admitted to the facility on June 11, 2015. Client # 1 receives medical assisted funding and required to have treatment plans signed by the doctor. The facility documented a treatment plan on July 9, 2015; however, the facility failed to ensure the treatment plan was signed and in compliance with 55 Pa. Code Part III, at the time of review.
Client # 2 was admitted to the facility on February 19, 2015. Client # 2 receives medical assisted funding and required to have treatment plans signed by the doctor. The facility documented treatment plans on May 8, 2015 and August 3, 2015; however, the facility failed to ensure the treatment plans were signed and in compliance with 55 Pa. Code Part III, at the time of review.
Client # 6 was admitted to the facility on March 26, 2015. Client # 6 received medical assisted funding and required to have treatment plans signed by the doctor. The facility documented treatment plans on June 30, 2015 and August 24, 2015; however, the facility failed to ensure the treatment plans were signed and in compliance with 55 Pa. Code Part III, at the time of review.
Client # 7 was admitted to the facility on October 15, 2014 and discharged on June 4, 2015. Client # 7 received medical assisted funding and required to have treatment plans signed by the doctor. The facility documented treatment plans on March 18, 2015 and December 15, 2014; however, the facility failed to ensure the treatment plans were signed and in compliance with 55 Pa. Code Part III, at the time of discharge.
Client # 9 was admitted to the facility on February 6, 2015 and discharged on July 27, 2015. Client # 9 received medical assisted funding and required to have treatment plans signed by the doctor. The facility documented treatment plans on May 11, 2015 and July 16, 2015; however, the facility failed to ensure the treatment plans were signed and in compliance with 55 Pa. Code Part III, at the time of discharge.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Chances Psychiatrist will review the charts that were noted to have been unsigned and update as necessary. Going forward the Psychiatrist will review all treatment plans weekly and sign by the 15th day following intake and sign every 60 days during the duration of treatment.
The clinical director and TQM will perform monthly chart audits to ensure that each review and updated treatment plan shall be dated,documented and signed in the participants record by the Psychiatrist, to comply with 55 Pa.
Compliance with this policy required by 55 Pa. will be reviewed and monitored by the program director via monthly supervisions and chart audits. |