INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System DD/FIR 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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705.2 (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 observations on August 9, 2012, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
The findings include:
A physical plant inspection was conducted on August 9, 2012. It was observed during the physical plant inspection from approximately 12:00 P.M. to 12:30 P.M., that there were areas in the employees and visitors' parking lot that had potholes.
The findings were confirmed during an interview with the building director on August 9, 2012 at approximately 12:30 P.M.
This is a repeat citation. The facility was cited on August 15, 2011 for noncompliance with this standard.
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Plan of Correction
All of the potholes in the visitor's and employee parking lot have been repaired. The Facilities director will be responsible for insuring that the lot is inspected on a monthly basis and that the lot is maintain in order to avoid and or repair new potholes. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on observations during the physical plant inspection on August 9, 2012, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating for each 2, 000 square feet or fraction thereof.
The findings include:
A physical plant inspection was conducted on August 9, 2012. It was observed during the inspection from approximately 1:00 P.M. to 1:30 P.M and from approximately 3:00 P.M. to 3:15 P.M., that there were only 2 portable ABC fire extinguishers on the 4th floor of the ADC Building in the MIP I Program. However, the 4th floor of the ADC Building in the MIP I Program had approximately 8, 000 square feet.
The findings were confirmed during an interview with the building director on August 9, 2012 at approximately 3:20 P.M.
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Plan of Correction
The facilities director, Fire Marshal and safty officer will confirm the square footage and purchase an adequate number of ABC Fire extinguishers for 4ADC by September 15, 2012, The Facilities Director will have the extinguishers installed by 9/22/12 and the Fire Marshal will insure monthly inspection and maintenace of equipment on an ongoing basis. |
711.51(b)(5) LICENSURE Physical Examination
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations in three of five client records.
The findings include:
The facility's policy titled: Bio-Psychosocial Assessment Process," states: "A History & Physical examination to be conducted by a licensed physician within:
1)24 hours of admission on St. Joseph's Detoxification and Rehabilitation Program.
2) 7 days of admission for DDFIR, Dual Diagnosis RTFA, Torre DE LA Raza and the Return Program."
On August 9, 2012, five client records were reviewed. The facility did not document a physical examination in three of five client records, specifically, client records # 2, 4, and 5.
Client # 2 was admitted on April 16, 2012. The physical examination was due by April 23, 2012. Client record # 2 did not include documentation of a physical examination as of August 9, 2012.
Client # 4 was admitted on March 20, 2012. The physical examination was due March 27, 2012. Client record # 4 did not include documentation of a physical examination as of August 9, 2012.
Client # 5 was admitted April 27, 2012. The physical examination was due May 4, 2012. Client record # 5 did not include documentation of a physical examination as of August 9, 2012.
The findings were confirmed during an interview with the facility director's personal assistant on August 9, 2012 at approximately 4:00 P.M.
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Plan of Correction
The Director of Residential Services will review the policy regarding physical examination with the staff doctor; with specific review of the need to sign and date all physical in order to insure compliance with Policy and Procedures. Compliance will be achieved immediately and will be monitored by the Staff Nurse on a daily basis in relationship to new admissions to the unit. The physical examinations for clients 2, 4 and 5 have already been completed. The Staff Nurse will be responsible for insuring that physical examinations are completed, signed and dated on time. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. 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 psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusion/impressions in four of five client records.
The findings include:
The facility's policy titled: "Bio-Psychosocial Assessment Process," states:
"A Integrated Psychosocial Evaluation will be completed by the Behavioral Specialist/Counselor/Counselor Assistant or Social Worker identifying the presenting problems, including an evaluation of the consumers strengths and weaknesses, barriers to treatment, problems which can and cannot be resolved through treatment and that might inhibit treatment, the potential or available supports, the consumers preferred coping mechanisms, the consumers appearance, behavior and reactions during the intake process and conclusions regarding the consumer attitude toward and ability to participate in the treatment process."
On August 9, 2012, five records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusion/impressions in four of five records reviewed, specifically, client records # 1, 2, 3, and 5.
Client # 1 was admitted on February 28, 2012. The psychosocial evaluation was completed February 29, 2012. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 2 was admitted on April 16, 2012. The psychosocial evaluation was completed on April 17, 2012. The psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, attitude toward treatment, and counselor conclusions/impressions.
Client # 3 was admitted on April 5, 2012. The psychosocial evaluation was completed April 9, 2012. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, and attitude toward treatment.
Client # 5 was admitted on April 27, 2012. The psychosocial evaluation was completed April 30, 2012. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and negative factors.
The findings were confirmed during an interview with the facility director's personal assistant on August 9, 2012 at approximately 4:00 P.M.
This is a repeat citation. The facility was cited on August 15, 2011; August 19, 2010; September 23, 2009; August 21, 2008; November 1, 2007; December 21, 2006; October 5, 2005; and December 9, 2004; for noncompliance with this standard.
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Plan of Correction
The clinical supervisor will provide and inservice training session utilizing an evaluation identified during the review as meeting state quidelines with all of the clinical staff. The supervisor review and sign all evaluation to ensure that they meet policy quidelines. The clinical supervisor will focus supervision for the next 60 days on this area. Full compliance will be acheived by 10/30/12. The clinical supervisor will monitor for ongoing compliance on a monthly basis. |
711.53(a)(6) LICENSURE Aftercare Plan
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan that included the client's future goals and/or future goals with time frames in three of three client records.
The findings include:
The facility's policy titled: "Aftercare Planning," states:
"It is the policy of NPHS to provide Aftercare Plans to all consumers who complete treatment and who will no longer be involved in formal drug and alcohol treatment services ... ...Aftercare plans will be completed only on those consumers who are leaving all levels of care. Aftercare plans as described in section 711.53 are not required for clients who leave treatment AFA, or AWOL ' s or for those who refuse to participate in aftercare planning. Aftercare plans will include short and long term goals to be worked on by the consumer following formal treatment. Aftercare plans will include the criteria for re-entry into the programs."
On August 9, 2012, three client records requiring documentation of an aftercare plan were reviewed. The facility did not document an aftercare plan that included the client's future goals with time frames in two of three records reviewed, specifically client records # 6 and 8.
Also, the facility did not document an aftercare plan that included the client's future goals in one of three records reviewed, specifically, client record # 7.
Client # 6 was admitted May 17, 2011 and was discharged February 23, 2012. The aftercare plan was completed on February 23, 2012, but the client's future goals on the aftercare plan did not include time frames.
Client # 7 was admitted May 27, 2011 and was discharged January 17, 2012. The aftercare plan was completed on January 17, 2012, but did not include the client's future goals.
Client # 8 was admitted June 20, 2011 and was discharged March 23, 2012. The aftercare plan was completed on March 23, 2012, but the client's future goals on the aftercare plan did not include time frames.
The findings were confirmed during an interview with the facility director's personal assistant on August 9, 2012 at approximately 4:00 P.M.
This is a repeat citation. The facility was cited on August 15, 2011 for noncompliance with this standard.
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Plan of Correction
The Director of Residential Services will review the Aftercare Policy with the clinical supervisor and counselors to insure compliance with the policy and the use of the correct forms (discharge instructions vs. aftercare plans). The Clinical supervisor will monitor on a monthly basis all discharges to insure that consumers in need of aftercare plans have them completed. The clinical supervisor will be responsible for ensuring that the aftercare plans include future goals with time frames.Full Compliance with policy will be achieved by 9/30/12/ |