INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9-10, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Report" for the two facility's that make up the Project was reviewed. The "Staffing Requirements Facility Summary Reports" completed by the facility's on January 9, 2013 and January 16, 2013 listed a combined total of 18 counselors and 3 staff identified as Clinical Supervisors. However two of the staff identified as clinical supervisors each have their own caseload and the third staff person identified as a clinical supervisor also serves as the facility director at other location.
The total number of drug and alcohol counseling hours per week provided by the Project equates to 17 FTE counselors within the Project, and therefore the project is required to have at least 2 full-time clinical supervisors. The "Staffing Requirements Facility Summary Reports" did not identify a full-time clinical supervisor at either of the Project's two facility's.
The findings were reviewed with the Facility Director during the inspection and at the exit interview on January 16, 2013. However, during the inspection the Facility Director disputed the findings, but was not able to provide further documentation.
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Plan of Correction
Plan of Correction:
The project employs the equivalent of 17 FTE clinicians (11 at NARP, 4 at IOP, and 1 at the Outreach Program). Therefore, to meet the standard of one full-time supervisor per eight counselors, a total of two full-time clinical supervisors would be needed. To ensure compliance, we will ensure that the two current clinical supervisor's caseloads do not exceed five patients at any time. In addition, we are in the process of filling a supervisory position that became vacant following an unexpected death. It is anticipated that following recruitment that this position will be filled by mid-April.
The Division Director is responsible for ensuring the corrective action is implemented. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that there were no heaters that were not permanently mounted or installed within the facility.
The findings include:
A physical plant inspection was conducted on January 10, 2013. It was observed during the inspection that a space heater was in room H 06 Conference Room at approximately 9:00 A.M.
The findings were confirmed on January 10, 2013 at approximately 10:40 A.M. during an interview with the Facility Director and Grant Coordinator.
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Plan of Correction
Plan of Correction: The space heater was removed from the conference room immediately. This heater was the personal property of a Jefferson employee from outside the Outreach Program; the Facility Director notified this person and all Outreach staff of the Department of Health policy that no space heaters are to be used in the facility. The facility director inspected all Outreach offices. It was suggested that if office temperature is an issue in the future, staff store additional clothing in their offices or contact the building maintenance director to have the thermostat adjusted. |
711.14(b)(4) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity.
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Observations
Based on a review of client records, and a discussion with the Facility Director, the facility failed to notify the Department of a change in activity.
The findings include:
On January 9-10, 2013, eleven client records were reviewed for compliance with licensure regulations. The facility documented that they were providing Suboxone treatment services, an activity for which they do not have Departmental authorization in one of eleven records reviewed, specifically client record # 3.
Client # 3 was admitted to the program on 6/7/12. Client # 3's record contained documented medical records and Physician's notes which indicated that client # 3 was receiving Suboxone treatment.
The Facility Director confirmed the findings.
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Plan of Correction
The Facility Director will complete the application regarding the prescription of suboxone at this site. The application will then be submitted to the Department of Drug and Alcohol Programs/DDAP. Once such an exception is granted, the Project will follow all guidelines regarding prescription of suboxone. The Facility Director is responsible for ensuring the corrective action is implemented by March 15th, 2013. Until the exception has been officially granted by the State, the Facility will not offer this service to any additional patients. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan in accordance with facility policy in three of ten records reviewed.
The findings include:
On January 9-10, 2013, nine client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility failed to document an individual treatment and rehabilitation plan according to policy in three of ten records reviewed; in particular client records # 5, 7 and 10.
The facility policy states "The Comprehensive Treatment Plan is to be completed after the completion of the bio-psychosocial evaluation, 30 days after the patient is admitted into the program."
Client # 1 was admitted to the program on 9/24/12, and at the time of inspection was still an active client. The individual treatment plan was due within 30 days. The facility failed to document an individual treatment plan for client # 1 within 30 days or by 10/24/12.
Client # 5 was admitted to the program on 5/24/12. The individual treatment plan was due within 30 days or by 6/24/12. The facility documented a late individual treatment plan on 7/5/12.
Client # 7 was admitted to the program on 10/15/12. The individual treatment plan was due within 30 days or by 11/15/12. The facility documented a late individual treatment plan on 12/11/12.
Client # 10 was admitted to the program on 5/30/12. The individual treatment plan was due within 30 days or by 6/30/12. The facility documented a late individual treatment plan on 7/18/12.
The Facility Director did not dispute the findings.
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Plan of Correction
1. The Facility Director will meet with counseling staff by 3/15/13 to establish a policy on more effectively communicating attendance requirements to new patients within the program. Beginning 3/20/13, it is to be clearly communicated to each patient upon intake(via a paper they must sign) that they are to attend sessions as scheduled and, if there is a patterned absence, they will be discharged due to non-compliance.
2. The facility director/clinical supervisor will do a random review of records quarterly to ensure that counselors are completing treatment plans within 30 days, and if clients are not attending sessions per plan the counselor will contact client for re-engagement or terminate the client per facility policy.
3. The facility director will be responsible for ensuring that treatment plans are completed in accordance with facility policy.
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711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document a complete client record which included an aftercare plan in one of one record reviewed.
The findings include:
The facility policy states "Aftercare plans are plans patients develop to establish future goals and objectives for a period of time after completion of treatment. The patient and counselor work out the aftercare plan during the last treatment sessions. The aftercare plan defines the aftercare program, follow-up activities and re-entry criteria for a patient."
One client record requiring documentation of an aftercare plan was reviewed on January 10, 2013, specifically client record # 10.
Client # 10 was admitted to the program on 5/30/12 and discharged on 12/26/12. The facility failed to document a complete client record which included an aftercare plan as of 1/10/13.
The Facility Director reviewed the record and confirmed the findings.
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Plan of Correction
The Facility Director will meet with counseling staff to establish a new procedure for discharge. Each time a patient is approaching discharge, the Facility Director will review all pending discharges with clinicians. In those cases where a planned discharge is forthcoming, the aftercare plan will be presented for review. In this manner, no client with a plan for discharge will leave treatment without an aftercare plan in place. The Facility Director is responsible for ensuring this action will occur by March 15, 2013. |
711.94(c) LICENSURE Display Emerg. Telephone Number
711.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on observation during the physical plant inspection, the facility failed to display an emergency telephone number to the general public.
The findings include:
A physical plant inspection was conducted on January 10, 2012 at approximately 9:00 AM. The facility failed to display an emergency telephone number to the general public.
The Facility Director confirmed the findings.
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Plan of Correction
A phone number has been placed in the patient waiting area, along with other patient information for the Outreach Program. It is the responsibility of the Facility Director to 1-ensure the completion (already complete) and 2-check quarterly to ensure the paper is still present in the waiting area. |