INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2013 to January 24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center of Thomas Jefferson University (MATER) 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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704.11(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.
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Observations
Based on a review of the personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff.
The findings include:
On January 22, 2013 and January 23, 2013, six personnel records were reviewed to verify that employees had STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received a minimum of 4 clock hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in one of six personnel records reviewed, specifically, personnel record # 4.
Employee # 4, a counselor, was hired May 16, 2011. Employee # 4 was due to complete 4 clock hours of STD/TB training by May 16, 2012. However, employee # 4 did not complete STD/TB training until September 28, 2012.
The findings were confirmed during an interview with the facility director on January 23, 2013 at approximately 9:30 A.M.
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Plan of Correction
#1 - Required trainings will be flagged on all counselors on a monthly notice to ensure compliance for mandatory trainings and required training hours
#2 - Administration will research local trainings that meet requirements; notify supervisor and staff of dates, times, and location of training; supervisor will sign-off on training request
#3 - Supervisor will permit all counseling staff the administrative time required to meet compliance and submit copies of certificates to Administration for verification of attendance.
Person Responsible(s): Administrative Assistant to the Program Director and Clinical Supervisor
Timeframe for completion:
#1, #2, & #3 - Immediate compliance for all of the above have been implemented.
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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 client records, the facility failed to document follow-up information in accordance with their policy and procedures in seven out of seven records reviewed.
The findings include:
The facility's policy titled: "Follow-Up Policy," states:
"Follow up determines the status of a patient who has been referred to an outside service provider or who has been discharged from the program or who is AWOL. The following procedures are to be followed:
If the patient ... ...will note that fact in a progress note.
a.All patients regardless of their discharge status, are contacted 7 days of discharge to determine if the patient is:
1.attending outpatient services and where
2.is the patient remaining drug free
3.is the patient attending 12 Step meetings
4.does the patient have a sponsor
5.is the patient engaged in school, job training, work, etc.
6.is the patient keeping all medical appointments for self and children
7.a general report on the patient ' s daily activities
8.would the patient like to be part of the MSP alumni."
On January 23, 2013, seven records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information according to their policy and procedures in seven of seven records reviewed, specifically, client records # 7, 8, 9, 10, 11, 12, and 13.
Client # 7 was admitted November 25, 2011 and was discharged August 17, 2012. The follow-up information was due August 24, 2012; however, the follow-up information was not completed until September 18, 2012.
Client # 8 was admitted July 23, 2007 and was discharged October 4, 2012. The follow-up information was due October 11, 2012; however, the follow-up information was not completed until November 2, 2012.
Client # 9 was admitted November 18, 2011 and was discharged November 6, 2012. The follow-up information was due November 13, 2012; however, the follow-up information was not completed until December 6, 2012.
Client # 10 was admitted January 6, 2012 and was discharged August 13, 2012. The follow-up information was due August 20, 2012; however, the follow-up information was not completed until September 13, 2012.
Client # 11 was admitted January 27, 2012 and was discharged September 10, 2012. The follow-up information was due September 17, 2012; however, the follow-up information was not completed until October 7, 2012.
Client # 12 was admitted June 4, 2010 and was discharged October 9, 2012. The follow-up information was due October 16, 2012; however, the follow-up information was not completed until November 6, 2012.
Client # 13 was admitted August 27, 2009 and was discharged October 4, 2012. The follow-up information was due October 11, 2012; however, the follow-up information was not completed until November 2, 2012.
The findings were confirmed during an interview with the clinical supervisor on January 23, 2013 at approximately 3:00 P.M.
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Plan of Correction
The Residential 7 - day Follow-Up page was inadvertently included in OutPatient P & P. The page has been removed. The revised policy stating 30 days has been approved by the Project Director and included in the P & P. the Program Director will be responsible to ensure the policy is retained in the P & P. As per the revised policy, all 30 day follow-ups on discharged patients are completed by the Receptionist and monitored monthly by the Administrative Clinic Coordinator for compliance.
Person(s) Responsible: Program Director, Administrative Clinic Coordinator, and Receptionist.
Timeframe for correction: Immediate |
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 observations on January 23, 2013, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
The findings include:
A physical plant inspection was conducted on January 23, 2013. It was observed during the inspection at approximately 10:36 A.M., that the facility did not have a telephone number displayed conspicuously to the general public for emergency purposes.
The findings were confirmed during an interview with the facility director on January 23, 2013 at approximately 10:37 A.M.
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Plan of Correction
Upon notification of the deficiency at approxiamtely 10:36AM, the telephone number was immediatley stapled to the Patient's Information board in the main lobby area. The receptionist will check to ensure the sign is posted on a monthly basis. If the sign has been removed, the receptionist will replace the number on the board.
Person(s) responsible: Program Director, Receptionist
Timeframe for completion: Immediately corrected on 1/23/13 at approxiamtely 10:30AM. |