INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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 and a plan of correction is due on October 24, 2009.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records, the facility failed to document feedback forms in two of five records reviewed.
The findings include:
Five personnel records were reviewed on September 16, 2009. Feedback forms were required in two personnel records reviewed. Personnel records #2 and 4 failed to document feedback forms after every training attended for training year 2008.
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Plan of Correction
The secretary of the Residential Services programs will attach feedback forms to all training certificates and will collect them prior to filing the certificates. The secretary and Program Directors/Clinical supervisors will monitor completion of forms on a quarterly basis. Compliance will occur immediately |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a tour of the facility's physical plant, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
The findings include:
A tour of the facility's physical plant was conducted on September 23, 2009 at approximately 9:30 AM. The facility was required to provide slip-resistant surfaces in all bathtubs and showers. The facility did not provide slip-resistant surfaces for the showers in client bedrooms # 1005 and 1006.
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Plan of Correction
The NPHS maintenace department has developed a schedule for applying slip resitence spray to all shower stalls. This schedule will be monitored by the head of facilities Management and will begin immediatley and be ongoing according to the manufactures recommended schedule of application. The Program director will monitor this effort during monthly facilites rounds.
Full compliance will be achieved by December 1, 2009
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a tour of the facility's physical plant, the facility failed to ventilate all toilets and wash rooms by exhaust fan or window.
The findings include:
A tour of the facility's physical plant was conducted on September 23, 2009 at approximately 9:30 AM. The facility was required to ventilate all toilets and wash rooms. The facility did not provide an exhaust fan or a window for one or the two staff bathrooms.
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Plan of Correction
The maintenace department will install ventilation in the staff bathroom on or before November 31, 3009. Full compliance will be obtained by 11/31/09 |
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 in three of five client records.
The findings include:
Nine client records were reviewed on September 22, 2009. Psychosocial evaluations were required in five client records. The facility did not document a complete psychosocial evaluation in client records # 2, 3 and 4.
The facility did not document a psychosocial evaluation to include the client's preferred coping mechanisms in record # 1.
The facility did not document a psychosocial evaluation to include the client's negative factors that might affect treatment in record # 1.
Client records # 3 and 4 did not document a legible psychosocial evaluation as the content of the document was not able to be read due to the illegible handwriting contained in the patient
record.
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Plan of Correction
The NPHS Education department will schedule a series of 3 hour trainings on the appropriate completion of psychosocial evaluations. The Program Directors and clinical supervisors will review at least 3 evaluations per staff per month during clinical supervison. Full compliance is expected by January 1, 2010 |
711.58(a)(4) LICENSURE Control/accountability of Drugs
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of the medication policies and procedures and medication administration records on September 23, 2009, the facility failed to document complete medication records.
Findings:
Documentation failed to disclose reasons a client did not take their medication as prescribed in four medication charts out of nine records reviewed. Also, documentation did not indicate whether or not the client received their medication, if a client refused their medication or whether the medication was discontinued.
Client # 6
Drug: Penicillin VK 500 mg
Prescribed on 9/17/09
Frequency: 1 tablet 4 times a day
Dates not taken: 9/17/09, 9/18/09, 9/19/09 and 9/20/09 only took twice instead of 4 times a day.
Client # 7
Drug: Gabapentin 600 mg
Prescribed on 9/17/09
Frequency: 1 tablet 3x a day
Date not taken: 9/17/09 (only took once), 9/19-20-21-22/09 only took twice
Client #8
Drug: Ferrous Sulfate 325 mg
Frequency: 1 tablet 3x a day
Dates not taken: 9/22/09 only took twice
Client #9
Drug: Penicillin
Prescribed: 8/18/09
Frequency: Take one tablet by mouth every 6 hours until finished
Date not taken: 8/18/09 9pm
8/19/09 11:30 am
8/19/09 9pm
8/20/09 9pm
8/21/09 10pm
8/22/09 9:40
8/23/09 9am?
8/23/09 10pm
8/25/09 7:50am
8/28/09 9pm
8/29/09 9am
8/29/09 10:30pm
9/4/09 9am
9/6/09 9am
9/7/09 9am
9/8/09 10am
9/9/09 10:15am
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Plan of Correction
The NPHS Education Department will schedule a series of three to six, three hour inservice sessions on the self administration of medication. All addiction recovery assistants will be required to attend sessions and to past a post test. The Program Director/Clinical supervisors will be responsible to monitor the process on a weekly basis. The NPHS performance improvement department will conduct random monthly monitoring for the next six months to ensure compliance. Full compliance is expected by 12/15/09 |