INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Narcotic Addict Rehibition Program of Thomas Jefferson by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, February 17, 2021 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of nine personnel records, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.Employee # 4 was hired as a clinical supervisor July 16, 2019. At the time of the inspection, employee # 4 had no documentation of completing the core curriculum in clinical supervisor. These findings were discussed with facility during the inspection process.This is a repeat citation from January 30, 2020.
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Plan of Correction
It shall be the responsibility of the facility director to ensure compliance with the statute. In response to last year's citation, Employee # 4 was enrolled to complete a core curriculum in clinical supervision scheduled to be held by DDAP on March 24-27, 2020. Unfortunately the Covid-19 pandemic resulted in cancellation of that training, which has yet to be re-scheduled. Employee #4 will enroll and complete the DDAP core curriculum as soon as it is offered. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of nine personnel records and discussion with facility staff, the facility failed to ensure that employee #2 hired as the facility director on July 1, 2011 received twelve hours of training for the 2020 training year. At the time of the inspection, employee #2 only provided seven hours of training. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
It shall be the responsibility of the Clinical Operations Manager to ensure that all program staff for whom this standard applies are compliant with annual training hour requirements. Bi-annual review of cumulative training conducted by the Operations Manager will allow for timely feedback and provide facility staff who are deficient in annual training the opportunity to schedule and attend necessary trainings. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of eight patient records, the facility failed to ensure that each patient received at least a drug test monthly in all eight of the patient records reviewed.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
It is the responsibility of the Nursing Coordinator (NC), operating under the auspices of the medical director, to ensure compliance with this standard. To achieve compliance, the NC employs the automated dispensing system to randomly request drug screens from all clients on a monthly basis. These drug screens are collected and analyzed by the consulting laboratory. It shall be the responsibility of supervisory staff, during their review of clinical records, to ensure that drug screens are being being recorded in a manner consistent with the monthly standard. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of eight patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.Patient record #1 was admitted on June 16, 2020 and was still active at the time of inspection. The facility only documented 1.15 hours of psychotherapy in October 2020, 2 hours of psychotherapy in November 2020, and in December 2020 30 minutes of psychotherapy.Patient record #2 was admitted February 25, 2020 and was still active at the time of the inspection. The facility only documented 1 hour of psychotherapy in October 2020, 1 hour of psychotherapy in November 2020 and 2 hours of psychotherapy in January 2021. Patient record #6 was admitted on July 29, 2013 and was still active at the time of the inspection. The facility had no documentation of any psychotherapy hours since September 2020. Patient record #7 was admitted on April 7, 2020 and was still active at the time of the inspection. The facility only documented 1.5 hours of psychotherapy in August 2020, 1 hour of psychotherapy in September 2020 and 1 hour of psychotherapy in October 2020. Patient record #8 was admitted December 6, 2019 and was discharged on July 21, 2020. The facility only documented 45 minutes of psychotherapy in April 2020, 0 hours of psychotherapy in May 2020 and 1.5 hours of psychotherapy in June 2020. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Recognizing that the Covid-19 pandemic has played a significant role in contact and engagement difficulties, it nonetheless shall be the responsibility of Clinical Supervisory Staff to ensure that each patient receives 2.5 hours of clinical service in the first two years of enrollment.
To achieve this, during administrative supervision supervisory staff will conduct quarterly reviews of the clinical records of patients under two years of continuous enrollment to ensure either a) compliance with the standard, or b) documentation of missed sessions/engagement efforts. The introduction of an electronic health record later this year, will facilitate these reviews.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of eight patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician in three patient records. Patient #3 was admitted on November 9, 2018 and discharged on June 22, 2020. An annual reevaluation was due November 2019. At the time of the inspection there was no annual reevaluation documented. Patient #4 was admitted on January 20, 2015 and discharged on September 29, 2020. An annual reevaluation was due May 2020. At the time of the inspection there was no annual reevaluation documented.Patient #6 was admitted on July 29, 2013 and was still active at the time of the inspection. An annual reevaluation was due August 2019 and again in August 2020. However, at the time of the inspection no reevaluation had been documented since August 6, 2018. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
It shall be the responsibility of the Nursing Coordinator (NC), under the auspices of the medical director, to ensure compliance with this standard. Compliance will be obtained via NC development of a tracking sheet which identifies on a monthly basis those clients due for annual physician reevaluation. Review of the tracking sheet, which will be conducted by the Program Coordinator, will ensure compliance with this standard. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of eight client records, the facility failed to ensure that all client records included treatment plan updates at least every 60 days. Client #3 was admitted on November 9, 2018 and discharged on June 22, 2020. A treatment plan update was completed on December 14, 2019 and an update was due no later than February 14, 2020, however, no update was completed by the time of discharge. Client #6 was admitted on July 29,2013 and still active at the time of the inspection. A treatment plan was completed on November 16, 2020 and an update was due no later than January 16, 2020, however there was no update complete at the time of the inspection. Client #8 was admitted on December 6, 2019 and discharged on July 21, 2020. A treatment plan update was created April 27, 2020 and a treatment plan update was due no later than June 27, 2020, however no update was completed by the time of discharge. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
It shall be the responsibility of the supervisory staff to ensure that patients are participating in treatment plan updates with their counselors every 60 days. Counselors will update treatment plans with patients every 60 days and supervisors will conduct regular reviews of counselor charts to ensure that the staff are compliant with this regulation.
In the specific instances of clients 3 & 8 the deficiency was the direct result of delinquent discharge from treatment. The Program Coordinator will notify therapists of clients whose attendance pattern is resulting their discharge from treatment. Frome this notification, therapists will have 7 days to complete the required discharge paperwork. These efforts will ensure timely discharge from treatment following cessation of service delivery. |
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 eight client records, the facility failed to ensure that all applicable client records include an aftercare plan. Client record #3 was admitted on November 9, 2018 and discharged on June 22, 2020. The client record failed to include an aftercare plan.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Aftercare planning, the process of preparing for a time following treatment, should ideally begin at the time of enrollment. Thus the Intake Coordinator will with client cooperation complete a preliminary Aftercare Plan at the time of admission and place it in the record. As needed, this document will be reviewed and updated. It shall be the responsibility of the Program Coordinator, who directly supervises the actions of the Intake Coordinator, to ensure that Aftercare Plans are in place for all clients. A random review of charts will ensure compliance with the standard. |
711.93(a)(7) LICENSURE Follow-up Information
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:
(7) Follow-up information.
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Observations
Based on a review of eight client records, the facility failed to include follow up information in three applicable records. Client #3 was admitted on November 9, 2018 and discharged on June 22, 2020. Client #5 was admitted on November 18, 2018 and discharged on August 6, 2020. Client #8 was admitted on December 6, 2019 and was discharged on July 21, 2020.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
It shall be the responsibility of the Program Coordinator to ensure that follow up procedures are conducted with clients who are discharged from the program and who do not pose behavioral concerns that would prohibit them being readmitted to the program. The Program Coordinator will instruct the counselor to ensure that efforts to reach patients are documented either by including copies of the completed follow-up forms in the patient's chart or documenting unsuccessful follow up efforts in the progress notes section of the chart.
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