INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the September 17, 2009 licensure renewal inspection. The follow-up inspection was conducted on March 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, North Philadelphia Health System - Return Program 1 & 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
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Plan of Correction
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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 psychosocial evaluations in five of seven clients records reviewed.
The finding includes:
Seven records were reviewed on March 16, 2010. Psychosocial evaluations were required in seven records reviewed.
The facility failed to document in client record #1 an evaluation of the client # 1's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client's attitude toward treatment and the counselor conclusions/impressions.
The facility failed to document in client record #2 an evaluation of the client # 2's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client's attitude toward treatment and the counselor conclusions/impressions.
The facility failed to document in client record # 3 an evaluation of the client # 3's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client's attitude toward treatment and the counselor conclusions/impressions.
The facility failed to document in client record # 4 an evaluation of the client # 4's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client's attitude toward treatment and the counselor conclusions/impressions.
The facility failed to document in client record # 6 an evaluation of the client # 6's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client's attitude toward treatment and the counselor conclusions/impressions.
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Plan of Correction
The clinical supervisor will conduct focused supervision around the completion of psychosocial evaluations, conducting a 100% review of records over the next sixty days. Individual training will be provided to each of the clinicain during this time frame. 100% compliance is to be achieved by May 31, 2010. Ongoing supervision and review of records will be conducted by the clinical supervisor and PI department to ensure compliance. |
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 the review of the facilities medication administration records for twelve clients, the facility failed to maintain accurate records on the individual medications.
The findings include:
Twelve medication administration records were reviewed on March 16, 2010. Six of those listed inventory records that were inconsistent.
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Plan of Correction
The clinical supervisor will review the charts in question to determine if the same staff member is providing inconsistent counts, and will provide additional training to any staff member to whom this issues applies. In addition the clinical supervisor will conduct an additonal training session on or before April 15, 2010 regarding the importance of accurate medication counts. The pharmacy department has provided medication counting trays for use of the unit to encourage more accurate counts. The supervisor will conduct weekly monitoring of this issue. Compliance will be achieved by May 1, 2010 |