INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 5, 2023 through December 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of 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:
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Plan of Correction
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715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of patient records, the narcotic treatment program failed to verify that the individual reached 18 years of age prior to the administration of an agent in two of two applicable patient records reviewed.
Patient #1 was admitted on February 17, 2023 and was still active at the time of the inspection. There was no documentation in the record that the patient's age was verified prior to the administration of a narcotic agent.
Patient #5 was admitted on November 3, 2022 and was discharged on March 24, 2023. There was no documentation in the record that the patient's age was verified prior to the administration of a narcotic agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake navigators will ensure a copy of photo ID with name, birthdate (proof of age), and proof of address is added to chart during intake process by adding task to the checklist of requirements. Staff will provide patients without a photo ID access to acquiring a valid photo ID. Leadership will also conduct chart audits quarterly to ensure each chart has a valid photo ID with proof of age. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the narcotic treatment program failed to verify the individual's identity, including the name, address, and date of birth, prior to the administration of an agent in two of two applicable patient records reviewed.
Patient #1 was admitted on February 17, 2023 and was still active at the time of the inspection. There was no documentation in the record that the patient's identity was verified prior to the administration of an agent.
Patient #5 was admitted on November 3, 2022 and was discharged on March 24, 2023. There was no documentation in the record that the patient's identity was verified prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake navigators will ensure a copy of photo ID with name, birthdate (proof of age), and proof of address is added to chart during intake process by adding task to the checklist of requirements. Staff will provide patients without a photo ID access to acquiring a valid photo ID. Leadership will also conduct chart audits quarterly to ensure each chart has a valid photo ID with proof of age. |
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 patient records, the narcotic treatment program failed to complete and document a random urinalysis, for each patient, at least monthly in two of seven patient records reviewed.
Patient #3 was admitted on September 21, 2021 and was still active at the time of the inspection. There was no documentation that a random urinalysis was conducted during the month of September 2023.
Patient #4 was admitted on August 23, 2016 and was discharged on August 3, 2023. There was no documentation that a random urinalysis was conducted during the month of May 2023.
This is a repeat citation from the January 19, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing supervisor will complete a report on the third week of every month that is pulled from the electronic data dosing data base, to identify any patients who have not received a UDS in the month to ensure all patients receive their monthly drug screening. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.
Patient #1 was transferred in and admitted on February 17, 2023 and was still active at the time of the inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership will add confirmation of transfer to screening process checklist to ensure former clinic is aware of patient's transfer. A form will be created to document the confirmed transfer, date of admission, and date of initial dose as well as verification of form clinic's awareness. |