INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 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 - Return Program 1 and 2 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 15, 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. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the facility failed to either document training plans or documented them late in two of five personnel records reviewed.
The findings include:
Five personnel records were reviewed on September 15, 2009. Training plans were required in four personnel records. Per the facilities policy and procedure, training plans will be developed by January 31 of each year. Employee record #2 was hired 7/92 and her training plan was documented on 9/2/09 per facilities policy was documented late. Record #4 did not have documentation of training plan for training year 2009 in employee record reviewed. Employee #4 was hired 12/2006.
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Plan of Correction
The secretary for the Residential Services department will continue to provide education plans to Program Directors by December 15th, she will provide a list of outstanding plans to the Program Directors/Clinical Supervisors by Jan 24th. The Director of Residential Services will monitor for compliance. Full compliance will be acheived by January 31, 2010. |
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
Based on a review personnel record, the facility failed to make sure that all staff is trained for 6 hours in HIV/AIDS and at least 4 hours of TB/STD training in the required amount of time in one of five records reviewed.
Findings:
Five personnel records were reviewed on September 15, 2009. Employee # 4 who is a counselor was hired December 2006 and is required to have TB/STD training by December 2007 and as of September 15, 2009 did not have the required trainings.
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Plan of Correction
TB/STD training is provided during New Employoee Orientation. Employee #6 recieved the training on 12/12/06, documentation is in the employee crendential file reviewed at the time of this inspection. A copy of the certificate will be faxed to the office. Mandatory trainings will be highlighted during reviews to avoid any oversight in the future.The Director of Residential Services will be responsible for ensuring the staff have attended and for highlighting Mandatory training certificates during the DOH reviews. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure and document that counselors completed at least 25 hours of training for the training year 2008 in one of two personnel records.
Findings:
Five personnel records were reviewed on September 15, 2009. The facility only documented 6 hours of training in employee #4's file for the training year 2008.
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Plan of Correction
The department secretary will provide quarterly reports to the Program Directs/Clinical supervisors regarding training hours completed. The Program Directors/Clinical supervisor will monitor training hours during montly supervison and schedule trainig to ensure compliance with regulations. Full compliance will be achieved by December 31, 2009. |
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 all of the client showers.
On the 7th floor, the facility did not provide slip-resistant surfaces for two of the four communal showers.
On the 9th floor, the facility did not provide slip-resistant surfaces for the showers in client bedrooms # 902, 903, 904, 905, 906, 907 and 908.
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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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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 five of six client records.
The findings include:
Ten client records were reviewed on September 17, 2009. Psychosocial evaluations were required in six client records. The facility did not document a psychosocial evaluation to include the client's assets/strengths, available support systems and the client's coping mechanisms in client records # 1, 2, 3, 5 and 6.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in records # 1, 3, 5 and 6.
The facility did not document a psychosocial evaluation to include the client ' s potential or available support systems in records # 1, 3, 5 and 6.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in records # 1, 5 and 6.
Client record # 2 did not document a legible psychosocial evaluation.
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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:
The facility failed to document whether or not a client received their medication, if a client refused their medication or whether the medication was discontinued or their medication was being taken as prescribed in four medication records reviewed. During the physical plant inspection the monitor confirmed that they did not know why there was no justification in the medication log records for deviation from the prescription directions.
Client # 7
Drug: Mirtazepine 15 mg
Prescribed on 8/27/09
Frequency: take one tablet at bedtime
Dates not taken: client refused to take meds. on 8/28/09, 8/29/09, 8/30/09, 9/3/09, 9/4/09. Also 9/4/09 was the last day that the client took his meds. no documentation as to why they client stop taking his meds.
Client #8
Drug: Humalog Inj 10 ML
Prescribed on 9/12/09
Frequency: 5 units 2x a day with breakfast and dinner 9am and 5pm
Date not taken: 9/12/09 (4pm) 10 units
9/13/09 (8am) 5 units
9/15/09 (9pm) 10 units
9/14/09 (8am) 5 units
9/15/09 (8am) 5 units
9/16/09 (8am) 5 units
9/17/09 (8am) 5 units
9/18/09 (8am) 5 units
9/19/09 (8am) 5 units
9/20/09 (8am) 5 units
9/21/09 (8am) 5 units
9/22/09 (8am) 5 units
9/23/09 (8am) 5 units
Client #9
Drug: Gabadentin 300mg
Prescribed: 9/10/09
Frequency: take one capsule by mouth three times a day
Dates not taken: 9/11/09 (only give twice)
9/13/09 (only given twice)
Client #10
Drug: Hydroxy PAM 50 mg
Prescribed: 9/12/09
Frequency: take 2 caps daily at bedtime
Date not taken: 9/13/09 (only documented that client took one pill count 58)
9/14/09 (only documented that client took one pill count 57)
9/15/09 (only documented that client took one pill count 56)
9/16/09 (only documented that client took one pill count 55)
9/17/09 (only documented that client took one pill count 54)
9/18/09 (only documented that client took one pill count 53)
9/19/09 (only documented that client took one pill count 52)
9/20/09 (only documented that client took one pill count 51)
9/21/09 (only documented that client took one pill count 50)
9/22/09 (only documented that client took one pill count 49)
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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. |