INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 26, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, My Sisters Place Thomas Jefferson University, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics trainings within the regulatory time frame in one of six personnel records reviewed.Employee #6 was hired as a behavioral health technician on November 23, 2020. The HIV/AIDS training was due to be received no later than November 23, 2022. However, the training was not completed as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
To ensure that all staff persons receive the required training hours on infectious diseases and other related topics within the regulatory timeframe, the My Sister's Place Thomas Jefferson University program submits the following Plan of Correction:
New hire employees will receive a list of all program-specific and local/state required trainings.
Immediate supervisors from each department will review the completion of these trainings with their staff. during scheduled supervision times and/or during departmental staff meetings.
Program Director, Residential Clinical Director or Operations Director can monitor if this requirement has been met when completing the annual assessment of staff training needs.
In the event that the My Sister's Place Thomas Jefferson University program experiences difficulty with scheduling staff for these required trainings, the program will document all efforts to schedule the training and will notify DDAP in writing of the barriers. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment plans were reviewed and updated at least every 30 days in four of seven client records reviewed.Client #1 was admitted on April 29, 2022 and was active at the time of inspection. A treatment plan update was completed on October 25, 2022 and the next update was due no later than November 25, 2022; however, the update was not completed until January 5, 2023.Client #3 was admitted on July 5, 2022 and was active at the time of inspection. A treatment plan update was completed on December 16, 2022 and the next update was due no later than January 16, 2023; however, the update was not completed until January 25, 2023.Client# 5 was admitted on December 16, 2021 and was discharged September 22, 2022. A treatment plan update was completed on May 26, 2022 and the next update was due no later than June 26, 2022; however, the update was not completed until July 25, 2022.Client # 6 was admitted on March 7, 2022 and was discharged July 6, 2022. A treatment plan update was completed on April 13, 2022 and the next update was due no later than May 13, 2022; however, the update was not completed until May 23, 2022.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
To ensure the My Sister's Place Thomas Jefferson University program reviews and updates treatment plans at least every 30 days, the program submits the following Plan of Correction:
The assigned Counselor will utilize the Electronic Health Record system (eCR) to keep track of all treatment plans coming due for update.
The assigned Supervisor will utilize the Electronic Health Record system (eCR) to run reports weekly of all treatment plans coming due and review them with each assigned Counselor during scheduled supervisions and/or Team meetings.
In the event that the assigned Counselor is unavailable to complete the treatment plan update, the assigned Supervisor will delegate another member of the Clinical Team (i.e., Lead Counselor, Lead Patient Navigator or Patient Navigator) to complete the treatment plan.
In the event that any of the aforementioned staff are unavailable to complete the treatment plan update, the assigned Supervisor will complete the treatment plan themselves. |