INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on January 28-30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of employee records and discussion with the facility staff, employee #4 was hired as a Clinical Supervisor on July 16, 2019. The facility failed to ensure that employee #4 completed a core curriculum in clinical supervision due to not having functioned for 2 years as a supervisor. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
It shall be the responsibility of the facility director to ensure compliance with the statute. In response, Employee # 4 has been scheduled to complete a core curriculum in clinical supervision held by DDAP on March 24-27, 2020. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for counselors in employee #2's employee record.Employee #2 hired as Facility Director on July 1, 2011 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July January 1, 2019 through December 31, 2019 . Employee #2's employee record only documented 11 hours of annual training for the training year reviewed.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
It shall be the responsibility of the Facility Director to ensure that all supervisory level employees complete the minimum training requirement. Quarterly ongoing review of training hours will ensure future compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #2's employee record.Employee #5 was hired as a counselor on February 20, 2018 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2019 through December 31, 2019. Employee #5's employee record only documented 8.6 hours of annual training for the training year reviewed.Employee #11 was hired as a counselor on March 14, 2016 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2019 through December 31, 2019. Employee #11's employee record only documented 10 hours of annual training for the training year reviewed.Employee #12 was hired as a counselor on September 22, 2017 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2019 through December 31, 2019. Employee #12's employee record only documented 18.5 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It shall be the responsibility of the Facility Director, as well as Clinical Supervisory personnel, to ensure that all counseling staff complete the minimum training requirement of 25 hours per year. Supervisory quarterly review of staff training hours will ensure future compliance. |
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.
|
Observations
Based on a physical plant inspection on January 30th, 2020, the facility had a portable space heater in the downstairs group room/employee break room. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
It shall be the responsibility of the Office Manager, under the auspices of the Facility Director, to ensure that no space heaters are present in the environment of care. Routine walk through will ensure compliance. Staff have been reminded of this requirement.
The space heater that was observed has been discarded. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection on January 30, 2020, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department as the fire extinguisher in the lobby expired in December 2018. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
It shall be the responsibility of the Office Manager, under the auspices of the Facility Director, to ensure that all fire extinguishers are reviewed annually. To ensure compliance, the Office Manager will review inspection/approval stickers annually. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
It was observed on January 28, 2020 that room 118 that stored closed client record in filing cabinets that were unlocked also had the door open and nobody attending the to the room. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
It shall be the responsibility of the Program Coordinator to ensure that regulations related to confidentiality of client records are met. During a routine staff meeting, clinical and support staff were instructed on the need to close and lock the door to the file room when exiting. The Program Coordinator will at random times monitor the status of the file room door and report her findings during administrative meetings. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that each patient recieves 2.5 hours of psychotherapy per month in the patients first 2 years. Client#10 was admitted on March 29, 2019 and was discharged on December 9, 2019. In September 2019, the client had 1 hour of individual therapy and 0 hours of group therapy. In August 2019, the client had 0 hours of individual therapy and 0 hours of group therapy. In June 2019, the client received 30 minutes of individual therapy and 0 hours of group therapy. In May 2019, the client received 30 minutes of group therapy and 30 minutes of individual therapy. There was no documentation of client no shows or cancellations during those time periods.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
It 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 requirement, or b) documentation of missed sessions/engagement efforts.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure that all clients received an annual physical examination. Client record #4 was admitted on September 9, 2013 and was still active at the time of inspection. An annual physical examination was due no later than December 14, 2019, however it was not documented as of the date of the inspection. These findings were discussed with facility staff at the time of the inspection.
|
Plan of Correction
The annual physical examination for client #4 has been completed since the date of inspection.
It shall be the responsibility of the medical director and nursing coordinator to ensure compliance with this regulation. As a short-term response, to ensure compliance a database of annual physical examination dates will be established by the nursing coordinator. This database will serve as a weekly prompt for scheduling annual physical evaluations. It is further anticipated that the introduction of an electronic health record later in the year will facilitate compliance with this regulation. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on a review of client records, the facility failed to ensure that each client received an annual evaluation of each patients status. Client Record #7 was admitted on December 2, 2014 and still active at the time of inspection. An annual evaluation was due no later than December 2, 2019, however there was no documentation as of the date of the inspection. These findings were discussed with facility staff during the inspection.
|
Plan of Correction
It shall be the responsibility od Clinical Supervisory staff to ensure compliance with the regulation regarding timely completion of the annual evaluation. Weekly administrative supervision shall be used to review counseling staff caseload dates of admission to ensure the timely completion of evaluations. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 8. Client Record#8 was admitted on July 26, 2019 and was discharged on August 4, 2019. A consent to release form was signed and dated on July 26, 2019 to the funding source. On August 26, 2019 a fax was sent to the funding source that released urine drugs screens. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
It is the responsibility of the Facility Director to ensure overall staff compliance with regulations regarding confidentially of patient records.
The limits of information that can be released have been reviewed with clinical personnel during individual supervision sessions as well as at a recent staff meeting. These limits will be reviewed with new personnel at their time of hire to ensure compliance. |