INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Methadone monitoring conducted on September 24, 2019 through September 26, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, North Philadelphia Health System - Goldman Clinic 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that 2 of 15 applicable employees reviewed received the minimum of six hours of HIV/AIDS training and four hours of TB/STD training within the regulatory timeframe.
Employee # 8 was hired as a counselor on December 11, 2017 and was due to have HIV/AIDS training and TB/STD training no later than December 11, 2018. The HIV/AIDS training was not completed until August 15, 2019.
Employee # 9 was hired as a counselor on March 12, 2018 and was due to have HIV/AIDS training and TB/STD training no later than March 12, 2019. The TB/STD training was not completed until August 14, 2019.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
#Director and clinical supervisor will review all new employees personal chart for evidence of HIV/AIDS,TB/STD and confidentiality training.
#New employee with no evidence of mandatory state training will be schedule for trainings within the regulatory timeframe by director or clinical supervisor.
#Clinical supervisors will review training hours during monthly individual supervision with each staff member to ensure this deficiency does not recur
Clinical supervisor will be ensure the corrective actions are implemented by October 11, 2019 |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct an unannounced fire drill for the months of October 2018 through August 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#The Fire Drill log was updated on 9/12/to include the amount of time it takes for evacuation the exit route used and the number of persons in the drill and to identify the specific programs involved in the drill in each building.
# The new log will be fully implemented by 10/30/19.
# The IS3 facility director is responsible for completing the log and conducting monthly fire drills.
The NPHS safety office will be responsible for monitoring the drill and reviewing the log reviewing on a monthly basis to insure that compliance is met.
A focus review will be conduct by the safety office over the next 90 days to insure accuracy and compliance- Completion 1-31-2020 |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to develop, and make available to the public, their annual report for the 2018 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No annual report for FY 2018 was completed because of the prior bankruptcy status of the institution.
The Sr. Vice President will complete and annual report for fiscal year ending June 30, 2019 by November 30, 2019.
Annual Report will be posted on the website by December 15, 2019
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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
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
No audit was completed for FY2018 because of the prior bankruptcy status of the organization.
The CFO is responsible for obtaining an audit for FY2019 and has engage a company to complete the audit.
Anticipated date of audit completion: December 30, 2019
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of eight client records.
Client # 1 was admitted on August 25, 2017 and was discharged on February 18, 2019. The record contained a consent to release information form to the funding source signed and dated by the client on December 12, 2018, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5. The information to be released included psychiatric evaluations, psychosocial histories, progress notes, history and physical exam, information regarding care provided and ongoing care needs.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms including the limitations imposed by 4 Pa. Code 255.5 with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated signature of a witness on a consent to release information form in one of eight records.
Client # 1 was admitted on August 25, 2017 and was discharged on February 18, 2019. There was a consent to release information form to an outside individual signed and dated by the client on June 11, 2018; however, the consent form did not include the dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms including the limitations imposed by 4 Pa. Code 255.5 with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to document the date, event or condition which the consent will expire on a consent form in three of eight client records.
Client # 1 was admitted on August 25, 2017 and was discharged on February 18, 2019. There was a consent to release information form to an individual signed and dated by the client on June 11, 2018; however, the consent form did not have a date, event or condition upon which the consent would expire.
Client # 2 was admitted on February 26, 2019 and was discharged on May 23, 2019. There was a consent to release information form to a case manager signed and dated by the client on April 8, 2019; however, the consent form did not have a date, event or condition upon which the consent would expire.
Client # 6 was admitted on December 5, 2018 and was discharged on July 17, 2019. There was a consent to release information form to another treatment provider signed and dated by the client on June 10, 2019; however, the consent form did not have a date, event or condition upon which the consent would expire.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review the accurate completion of consents forms including the limitations imposed by 4 Pa. Code 255.5 with all staff by 10/30/19.
The Clinical supervisor will conduct a focused monitor of all consent forms for accuracy and completion for 60 days concluding on 11/30/19
The Clinical supervisor will conduct ongoing random review of consent forms for accuracy and completion.
The Clinical supervisor will review all active cases and consents to ensure that they are complete and accurate by 10/30/19.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to notify the Department within 3 days following an unusual incident, which involved client deaths that were reported to the facility on the following dates:
January 23, 2019
February 27, 2019
April 1, 2019
June 17, 2019
June 21, 2019
August 12, 2019
September 10, 2019
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the policy regarding the reporting of Unusual Incidents to DDAP with the staff by November 1, 2019.
Copies of the Unusual Incident report form will be placed on the desk top of all clinicians and nursing stations for provide for easy access to the form.
The Clinical supervisor will perform a focus review for 60 days to be completed by December 31, 2019. Random ongoing review/monitoring will continue indefinitely thereafter.
Completion December 31, 2019
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to notify the Department within 3 days following an unusual incident, which required the presence of police personnel on February 28, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review the policy regarding the reporting of Unusual Incidents to DDAP with the staff by November 1, 2019.
Copies of the Unusual Incident report form will be placed on the desk top of all clinicians and nursing stations for provide for easy access to the form.
The Clinical supervisor will perform a focus review for 60 days to be completed by December 31, 2019. Random ongoing review/monitoring will continue indefinitely thereafter.
Completion December 31, 2019
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide at least one hour of onsite physician time a week for every ten patients in 7 weeks reviewed. The medical director and physician assistants timesheets were reviewed for the months of April, May, June, and July 2019. The following weeks were not in compliance:
-During the week of April 21-27, 2019, the patient census was 592. The facility was required to provide at least 60 physician hours. There were 41 physician hours documented.
-During the week of April 28, 2019 to May 4, 2019, the patient census was 586. The facility was required to provide at least 59 physician hours. There were 56 physician hours documented.
-During the week of May 13-19, 2019, the patient census was 574. The facility was required to provide at least 58 physician hours. There were 48 physician hours documented.
-During the week of May 20-26, 2019, the patient census was 573. The facility was required to provide at least 58 physician hours. There were 55 physician hours documented.
-During the week of May 27, 2019 to June 2, 2019, the patient census was 577. The facility was required to provide at least 58 physician hours. There were 46 physician hours documented.
-During the week of July 1-7, 2019, the patient census was 564. The facility was required to provide at least 57 physician hours. There were 48 physician hours documented.
-During the week of July 15-21, 2019, the patient census was 569. The facility was required to provide at least 57 physician hours. There were 55 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#Director,office manager and Medical Director will review the physician monthly schedule to ensure program coverage to prevent failure to provide at least one hour of on-site physician coverage a week for every ten patients in 7 weeks
# Director will request addition physician coverage from administration ,due to vacations or any other the reason that might affect medical staffing.
#To maintain full coverage of participants , if a physician is absent , the facility will reassign a physician from another on-site program who has knowledge of MAT.This corrective action will be implemented by October 11,2019 |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to complete a random, monthly urinalysis screening in five of eight client records.
Client # 3 was admitted on November 9, 2018 and was still an active client at the time of the inspection. There were no documented drug screen urinalyses for the months of January 2019, April 2019, June 2019 and July 2019.
Client # 4 was admitted on September 6, 2018 and was still an active client at the time of the inspection. There were no documented drug screen urinalyses for the months of May 2019 and June 2019.
Client # 6 was admitted on December 5, 2018 and was discharged on July 17, 2019. There were no documented drug screen urinalyses for the month of May 2019.
Client # 7 was admitted on July 18, 2018 and was still an active client at the time of the inspection. There were no documented drug screen urinalyses for the months of February 2019, April 2019 and June 2019 through August 2019.
Client # 8 was admitted on December 12, 2018 and was discharged on September 19, 2019. There were no documented drug screen urinalyses for the months of March 2019, May 2019, June 2019 and August 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager or administration support staff will print out daily a randomized list of participant to perform urine sample from Avatar system . The daily listing for urine samples will be provide to check-in clerk . Participant(s) will provide urine sample as upon request. If a participant is not compliant a clinical supervisor will be contacted. Counselor will review urine samples with participant during sessions and document results each month. Goldman Clinic participant are required to submit at least one random monitored urine per month. Participants are monitored by Nursing Staff via a monitor and security video camera located in the participant's restroom. Nursing Staff or Clinical Staff may request participant a breathalyzer exam, if necessary, before being medicated.Clinical supervisors monitor UDS monthly when they are doing their client file audits to ensure they are being done monthly.This corrective action will be implemented October 11, 2019. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility failed to document bi-annual dosage reviews in two of eight client records.
Client # 4 was admitted on September 6, 2018 and was still an active client at the time of the inspection. The last documented dosage review was dated on December 20, 2018.
Client # 5 was admitted on March 11, 2006 and discharged on August 14, 2019. The last documented dosage review was dated October 23, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
* Medical Director will perform a bi-annual dosage review on Client #4 by 0ctober 18 ,2019.
#Participant # 4 will be brought in to compliance on October 18 , 2019 , due to Medical Director performing a dosage review .
* To prevent recurrence of failure to document bi-annual dosage review
Medical Director will review each participant at least twice a year for the purpose of determining dosage level as per Policy 715.17 The Clinical supervisors will assure that a notation is made in the treatment plan as to notify Medical Director . This notation will remain in all treatment plans until 6 months passes. This is just a back up process as our computer generates a list of participants that are due for medication review each month that nurses utilizes to notify Medical Director. This will begin 10/20/2019.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to document the completion of an annual physical examination in one of eight client records reviewed.
Client # 4 was admitted on September 6, 2018. An annual physical examination was due by September 6, 2019; however, there was no documentation of an annual physical completed on file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
*The Nurse Physician will perform a annual physical examination on participant#4 by October 20 , 2019.
* To prevent recurrence of failure to document the completion of annual physical examination a monthly list will be completed at the beginning of each month, identifying participants due for annual physicals and re-evaluations. The Medical Director and Nurse Physician are responsible for all the re-evaluations. The Medical Director is also responsible for assuring the annual physicals and re-evaluations are being reviewed, signed, and completed. The clinical supervisors will complete monthly chart reviews to monitor this process is being followed as scheduled. This corrective action will be implemented by October 20 , 2019 .
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document an annual evaluation of the patient, to be completed by the patient's counselor and reviewed, dated and signed by the medical director in four of eight client records.
Client # 1 was admitted on August 25, 2017. The annual evaluation was due no later than August 25, 2018; however, it was completed on October 31, 2018. Additionally, the evaluation was not reviewed, dated and signed by the medical director.
Client # 4 was admitted on September 6, 2018. The annual evaluation was due no later than September 6, 2019; however, it was not completed as of the date of the inspection.
Client # 5 was admitted on March 11, 2006. The annual evaluation was due no later than March 11, 2019; however, it was completed on April 22, 2019. Additionally, the evaluation was not reviewed dated and signed by the medical director.
Client # 7 was admitted on July 18, 2018. The annual evaluation was due no later than July 18, 2019; however, it was completed on August 7, 2019. Additionally, the evaluation was not reviewed dated and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
#Participant #1 ,5 and 7 chart will be presented to Medical Director for review , signing and dating by October 20 ,2019.
# Participant#4 assigned counselor will completed annual evaluation and Medical Director review , sign and date by October 20 ,2019.
#Clinical supervisor will provide in-service training on the completion of annual evaluation and importance of notifying Medical Director of the need to review , sign and date document by October 25 ,2019 |