INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, North Philadelphia Health System - Torre De La Raza 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for three of seven applicable client records.
Client # 1 was admitted on March 4, 2021 and was still active at the time of inspection. The written procedure manual stated that case consultations will be completed at least monthly and documented in a treatment team note. There was no documentation of a case consult or treatment team note in the client record at the time of inspection.
Client # 3 was admitted on March 18, 2021 and was still active at the time of inspection. The written procedure manual stated that case consultations will be completed at least monthly and documented in a treatment team note. There was no documentation of a case consult or treatment team note in the client record for the month of April 2021.
Client # 7 was admitted on July 31, 2020 and was discharged on October 19, 2020. The written procedure manual stated that case consultations will be completed at least monthly and documented in a treatment team note. There was no documentation of a case consult or treatment team note in the client record for the month of August 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical supervisor will perform a in-service with about importance of completing case consultation monthly and documenting in treatment note by June 18,2021
*Clinical supervisor will review policy and procedure as it pertains to case consultation and documentation with staff by June 18 2021.
*Clinical supervisor will complete monthly chart audits to ensure that updated case consultation note are on record for each client by June 18,2021
Responsible Parties:
Clinical Supervisor.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.
Client # 3 was admitted on March 18, 2021 and was still active at the time of inspection. Release of information forms to a government agency and an insurance provider were signed and dated by the client on March 18, 2021; however, there was no documentation that a copy of either form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
*Clinical supervisor will review policy and procedure for completing Release of Information including ensuring that releases are completed in its entirety with staff by June 18,2021.
*Clinical supervisor will review the importance of documenting that a copy of consent form was provide to all clients , during a in-service by June 18,2021
* Clinical supervisor will complete monthly audits to ensure compliance by June 18,2021.
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a physical or sexual assault by staff or a client.
On January 11, 2020, a physical assault by a client occurred at the facility; however, there was no documentation that this incident was reported to the Department within 3 business days.
On March 17, 2021, a physical assault by a client occurred at the facility; however, there was no documentation that this incident was reported to the Department within 3 business days.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Incident reports will be submitted for all incidents noted in the citation by the administrative assistant of the Program by June 4, 2021.
Responsible party-Administrative Assistant
Date of compliance 6-4-2021
Beginning June 1, 2021 Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning June 1, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: June 4, 2021
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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
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
On April 9, 2021, an emergency medical team was called to the facility and a client was transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Incident reports will be submitted for all incidents noted in the citation by the administrative assistant of the Program by June 4, 2021.
Responsible party-Administrative Assistant
Date of compliance 6-4-2021
Beginning June 1, 2021 Clinical supervisors will submit copies of all incident reports to the administrative assistant who will any DDAP required reports within three (3) business days. The administrative assistant will maintain a log of all DDAP incident reports submitted and monitor on a monthly basis beginning June 1, 2021 and continue indefinitely.
Responsible Parties:
Clinical Supervisor & Administrative Assistant
Date of Compliance: June 4, 2021
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