INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23-24, 2018 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 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and 8 personnel records, the facility failed to document feedback forms with the required annual training as stipulated in the facilities Policy and Procedure Manuel.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Coordinator of Treatment, and Training to ensure that all staff members are completing feedback forms on completed trainings. A Training Feedback Form for all trainings already exists. The Coordinator of Treatment and Training will inform the staff that Training Feedback Forms are required for each training attended. When training certificates are provided to the Coordinator of Treatment and Training, they will only be accepted if they have a completed Training Feedback Form attached. They will be returned to the staff member if the Form is not attached. The Coordinator of Treatment and Training will track training hours, certificates received, and completed Training Feedback Forms in a spreadsheet. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted May 23-24, 2018, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside there counseling room.
The window covering on group room 205 did not cover the window entirely and a group was able to be seen at the time of the inspection.
The counseling session being conducted in a counselor's office, located on the 2nd floor rear, could be heard outside of the office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility Division Director to ensure privacy so that counseling sessions cannot be seen or hear outside the counseling room. The Division Director will ensure that blinds are installed in Group Room 205 and that they are closed at all times when group therapy sessions are occurring there to ensure that counseling sessions cannot be seen outside the room. The Division Director will also ensure that white noise machines will be placed directly outside of each counseling office to ensure that counseling sessions cannot be heard outside the room. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of 12 applicable records, the facility failed to document an initial face to face, document a 1 year opiate addiction, and document current opioid dependency in client record #6.
Client #6 was admitted on 05/08/17 and was still an active client at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Medical Director to ensure that the narcotic treatment physicians make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been dependent for at least 1 year prior to admission. The Medical Director will ensure that the Initial Physical Form is being completed at the time of each individual's admission for maintenance treatment, as this form contains the pertinent questions and directions for physical exam to ensure that each individual is evaluated for current dependency and dependency for at least 1 year prior to admission. As part of an initial review, the Program Coordinator will ensure completion before passing the record to counseling staff. |
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).
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Observations
Based on a review of 19 applicable records, the facility failed to document informed consent to release information forms in accordance with 42 CFR Part 2, 28 Pa. Code 709.28 and 4 Pa. Code 255.5(b) in 8 of 19 client records reviewed, specifically, client records # 6, 7, 9, 10, 11, 12.
Client # 6 was admitted on 05/08/17 and was an active client at the time of the inspection. There were 2 consent to release information forms dated 05/08/17 to a Government agency and Funder that states "that I am able to work a limited employment schedule".
Client # 7 was admitted on 04/11/16 and was an active client at the time of the inspection. There was a consent to release form dated 11/29/17 to a Government agency that states "that I am able to work a limited employment schedule".
Client # 9 was admitted 04/14/14 and was discharged on 06/05/17. Consent to release information forms dated 04/14/14/ to a government agency, an insurance carrier, a laboratory and another funding source were not updated.
Client #10 was admitted on 12/22/16 and discharged on 05/30/17. There was a consent to release information form dated 12/22/16 to a government agency/funding source that states "that I am able to work a limited employment schedule". A consent to release information form dated 12/22/16 to the emergency contact did not include what was being released.
Client # 11 was admitted on 04/29/16 and was an active client at the time of the inspection. A consent to release to "sister" dated 04/29/16 was missing an expiration date.
Client # 12 was admitted on 02/19/14 and was an active client at the time of the inspection. A consent to release information form dated 02/06/18 to an organization against domestic violence did not have a staff or witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It shall be the responsibility of the Coordinator of Treatment and Training to ensure that consent to release information forms are completed in accordance with 42 CFR Part 2, 28 Pa. Code 709.28 and 4 Pa. Code 255.5(b). The Coordinator of Treatment and Training will update all consent to release information forms so that they are in accordance with 42 CFR Part 2, 28 Pa. Code 709.28 and 4 Pa. Code 255.5(b) and train all staff members in how to ensure that they are completed in accordance with these regulations. At 3 and 6 months after staff members begin completing these new forms, the Coordinator of Treatment and Training will conduct random chart checks to ensure that the updated forms are being used and completed in accordance with 42 CFR Part 2, 28 Pa. Code 709.28 and 4 Pa. Code 255.5(b). Clients #6, 7, 9, 10, 11, and 12 will sign updated forms by 7/31/18. |
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 9 applicable records, the facility failed to document the date of the initial urine drug screen in 2 of 9 client records, specifically, client records # 5 and 15.
Client # 5 was admitted on 09/01/17 and was discharged on 04/12/18. There was no documentation indicating when the initial drug screen had been completed.
Client # 15 was admitted on 08/22/17 and was discharged on 11/7/17. There was no documentation indicating when the initial drug screen had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Medical Director and the Program Coordinator to ensure that initial drug screens are being completed on the day of admission. The Medical Director will continue to ensure that urine drug screens are being ordered at admission and the Program Coordinator will continue to check each admission chart to ensure that it has been completed. The Coordinator of Treatment and Training will ensure that this information is available to site visitors on inspection. Client #5 had initial drug screening completed on 9/1/17; and Client #15 had initial drug screening completed on 8/22/17. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of 15 applicable records, the facility failed to document a semi-annual review of dosage level in 8 of 15 records reviewed, specifically, client records # 6, 7, 9, 3, 4, 5, 13.
Client # 6 was admitted on 05/08/17 and was still an active client at the time of the inspection. The last documented review was on 08/18/17.
Client # 7was admitted on 04/11/16 and was still an active client at the time of the inspection. The last documented reviews were on 09/26/16 and 07/3/17. Reviews would have been due in March 2017 and January 2018.
Client #9 was admitted on 04/14/14 and was discharged on 06/05/17. No records of review were observed in the clients records.
Client # 3 was admitted on 07/12/17 and was still an active client at the time of the inspection. No records of review were observed in the clients records.
Client # 4 was admitted on 09/13/16 and was still an active client at the time of the inspection. No records of review were observed in the clients records.
Client # 5 was admitted on 09/01/17 and was discharged on 04/12/18. No records of review were observed in the clients records.
Client # 13 was admitted on 02/25/16 and was discharged on 06/19/17. No records of review were observed in the clients records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Medical Director to ensure that semi-annual dose reviews are completed for each patient. The Medical Director will maintain a spreadsheet with due dates of the semi-annual reviews for each patient and will complete each dose review as the due dates arise. The Head Nurse will assist her in maintaining this spreadsheet. Clients #7, 4, and 13 will receive dose reviews by 7/31/18. |
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 17 applicable client records, the facility failed to document 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 in accordance with the regulations in 5 of 17 records reviewed, specifically, client records # 6, 7, 4, 15, 16.
Client # 6 was admitted on 05/08/17 and was an active client at the time of the inspection. Client records show:
hour (I) counseling 04/19/18,
hour (I) counseling - 3/15/18,
.45 min (I) counseling - 3/1/18 and 03/06/18.
No (I) or (G) sessions for the month of February 2018 and January 2018.
hour (I) counseling - 12/22/17 & 12/8/17 and .40 min (I) counseling on 12/29/17.
hour (I) counseling - 11/17/17 and 11/3/17.
hour (I) counseling - 10/27/17, 10/20/17 and 10/06/17.
hour (I) counseling - 9/5/17.
hour (I) counseling - 7/5/17
Client # 7 was admitted on 04/11/16 and was an active client at the time of the inspection. Client records show:
hour (I) counseling - 4/25/18, 4/11/18 and 4/3/18
hour (I) counseling - 3/28/18, 3/7/18
1 hour (I) counseling - 2/22/18
No (I) and (G) counseling - January 2018 and December 2017
hour (I) counseling - 11/29/17 and 11/15/17
hour (I) counseling - 10/18/17 and 10/4/17
hour (I) counseling - 9/20/17 and 9/6/17
hour (I) counseling - 8/23/17
1 hour (I) counseling - 6/28/17
hour (I) counseling - 5/31/17 and 5/17/17
Client #4 was admitted on 09/13/16 and was still an active client at the time of inspection. Client records show:
In January 2018, the client had a total of 1.5 hrs
In February 2018, the client had a total of 1.75 hrs
In March 2018, the client had a total of 1 hr
In April 2018, the client had a total of 2 hrs
Client #11 was admitted on 09/01/17 and was discharged on 04/12/18. Client records show:
September 2017, the client had a total of 2 hrs
October 2017, the client had a total of 0 hrs
November 2017, the client had a total of 1 hr
December 2017, the client had a total of 1 hr
January 2018, the client had a total of 0 hrs
February 2018, the client had a total of 1 hr
March and April have no documentation of psychotherapy hours
Client # 15 was admitted on 03/10/17 and was discharged on 08/24/17. Client records show:
July 2017, the client had a total of .5 hrs
August 2017, the client had a total of 0 hrs
Client # 16 was admitted on 07/13/15 and was discharged on 02/20/17. The client records show:
August 2017, the client had a total of 2.25 hrs
September 2017, the client has a total of 1 hr
October 2017, the client had a total of 1 hr
November 2017, the client had a total of 1.75 hrs
December 2017, the client had a total of 0 hrs
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the supervisory staff to ensure that patients are being seen for 2.5 hours of psychotherapy per month during their first two years in treatment. The supervisory staff will hold in-service training on strategies for engaging patients on an ongoing basis. These strategies will include but are not limited to motivational interviewing, cognitive behavioral strategies, and contingency management. Supervisors will then follow up with clinical staff members on an individual basis to reinforce the use of these strategies and to aid clinical staff members in overcoming any barriers to patient attendance at counseling sessions. Clients #6, 7, and 4 will each be seen for 2.5 hours of individual therapy each by 8/31/18 and monthly thereafter. |
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 10 applicable client records, the facility failed to document an annual physical exam in 3 of 10 records reviewed, specifically client records #7, 12, and 17.
Client #7 was admitted on 4/11/16 and was an active client at the time of inspection. The last documented physical was 03/19/18 and there was no documented physical for 2017.
Client #12 was admitted on 07/13/15 and was discharged on 08/24/17. There was no documentation of an annual exam in the client records.
Client #17 was admitted on 12/14/16 and was discharged on 01/06/17. There was no documentation of an annual exam in the client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Medical Director and other medical personnel to ensure that each patient is completing an annual physical evaluation by a narcotic treatment physician. The Medical Director will continue to complete annual physical evaluations in a timely fashion. The Coordinator of Treatment and Training will ensure that this information is available to site visitors on inspection. Patient # 7 had annual physicals completed on 3/19/18 and 4/6/17; Patient #12 on 3/30/18 and 4/18/17; and Client #12 on 10/30/15 and 8/29/16. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on a review of 17 applicable client records, the facility failed to document case consultation notes in 3 of 17 records reviewed, specifically, client records # 5, 11, 2.
Client #5 was admitted on 09/1/17 and was discharged on 04/12/18. There was no documentation of a case consultation in the client record prior to discharge.
Client #11 was admitted on 03/10/17 and was discharged on 08/24/17. There was no documentation of a case consultation in the client record prior to discharge.
Client #2 was admitted on 07/13/15 and was discharged on 02/20/17. There was no documentation of a case consultation in the client record prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the supervisory staff to ensure that case consultation notes are being completed. Each member of the clinical staff will maintain a spreadsheet with due dates for case consultations and will complete them as due dates arise. Supervisory staff will ensure compliance by asking each staff member to present their case consultations at staff meetings when patient case consultation due dates arise. The Coordinator of Treatment and Training will ensure that this information is available to site visitors on inspection. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of 7 applicable client records, the facility failed to document an aftercare plan in client record # 5.
Client #5 was admitted on 09/01/17 and was discharged on 04/12/18. There was no aftercare plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Coordinator to ensure that Aftercare Plans are completed for each patient. The Program Coordinator will instruct the clinical staff to complete the Aftercare plan within 30 days after each patient is admitted and conduct an in-service training on how Aftercare Plans are to be completed. She will conduct random chart checks in 3 and 6 months after the in-service training to ensure that Aftercare Plans are in each new patient's chart and that they have been completed properly. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of 10 applicable records, the facility failed to document a discharge summary for client # 15.
Client #15 was admitted on 08/22/17 and was discharged on 11/7/17. There was no discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Coordinator to ensure that Discharge Summaries are being completed upon a patient's discharge from the program. Clinical staff will continue to complete discharges summaries on each discharged patient, which will then continue to be checked by the Program Coordinator. The Coordinator of Treatment and Training will ensure that this information is available to site visitors on inspection. Client #15's discharge summary was completed on 11/7/17. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of 8 applicable client records, the facility failed to document a follow-up in 5 of 8 client records reviewed, specifically, client records # 9, 10, 1, 2, and 14.
Client # 9 was admitted on 04/14/14 and was discharged on 06/05/17. There was no documented follow-up in the client record.
Client #10 was admitted on 12/22/16 and was discharged on 05/30/17. There was no documented follow-up in the client record.
Client # 1 was admitted on 03/10/17 and was discharged on 08/24/17. There was no documented follow-up in the client record. There was no documented follow-up in the client record.
Client # 2 was admitted on 07/13/15 and was discharged on 02/20/17. There was no documented follow-up in the client record.
Client # 14 was admitted on 10/28/16 and was discharged on 06/19/17. There was no documented follow-up in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Certified Recovery Specialist to ensure that follow-up information is being gathered on each patient. The Certified Recovery Specialist will continue to follow up with each patient at 60 days post-discharge and to document efforts to make contact with each patient and/or findings. The Coordinator of Treatment and Training will ensure that this information is available to site visitors on inspection. |
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.
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Observations
Based on a review of 17 applicable client records, the facility failed to document an annual evaluation in 3 of 17 records reviewed, specifically client records # 6, 7, and 9.
Client # 6 was admitted on 05/08/17 and was still an active client at the time of inspection. There was no documentation of an annual evaluation in the client record.
Client # 7 was admitted on 04/11/16 and was still an active client at the time of inspection. There was no documentation of an annual evaluation in the client record.
Client # 9 was admitted on 04/14/14 and was discharged on 06/05/17. There was no documentation of an annual evaluation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the supervisory staff to ensure that each patient receives an annual clinical evaluation. The supervisory staff will aid clinical staff in creating and maintaining a spreadsheet with information about each member of each counselor's caseload, including due dates for annual clinical evaluations. Counselors will refer to this spreadsheet weekly to determine which patients on their caseload have annual clinical evaluations due that week and will complete all annual clinical evaluations due by week's end. Supervisory staff will conduct a chart review at 3 and 6 months after initiation of this process to ensure that annual clinical evaluations are being completed in a timely fashion. Annual clinical evaluations for Clients 6 and 7 will be completed by 7/31/18. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of 15 applicable records, the facility failed to document a comprehensive treatment plan in 2 of 15 records reviewed, specifically, client records # 5 and 15.
Client # 5 was admitted on 09/01/17 and discharged on 04/12/18. There was no documented comprehensive treatment plan in the client record.
Client # 15 was admitted on 08/22/17 and was discharged on 11/07/17. There was no documented comprehensive treatment plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Program Coordinator to ensure that comprehensive treatment plans are completed for each patient. The Program Coordinator will instruct the clinical staff to complete the comprehensive treatment plan within 30 days after each patient is admitted and conduct an in-service training on how Treatment Plans are to be completed. She will conduct random chart checks 3 and 6 months following the in-service training to ensure that comprehensive treatment plans are in each new patient's chart and that they have been completed properly. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of 19 applicable client records, the facility failed to document treatment plan updates in 2 of 19 records reviewed, specifically, client records # 8, and 15.
Client # 8 was admitted on 02/20/18 and was an active client at the time of the inspection. There was no documentation of a treatment plan update in the record.
Client # 15 was admitted on 08/22/17 and was discharged on 11/7/17. There was no documentation of a treatment plan update in the record.
These findings were reviewed with facility staff during the licensing 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 continue to update treatment plans with patients every 60 days and supervisors will conduct regular reviews of counselor charts to ensure that the treatment plan updates are occurring every 60 days. The Coordinator of Treatment and Training will ensure that this information is available to site visitors on inspection. |
711.91(b)(4) LICENSURE Consent to Treatment
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of 20 applicable client records, the facility failed to provide documentation of a consent to treatment in 14 of 20 records reviewed, specifically, client records # 6, 7, 8, 10, 3, 4, 1, 2, 11, 12, 13, 15, 16, and 17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that documentation of consent to treatment is made available for the Intake Coordinator to complete during the admission process. The Facility Director will create a Consent to Treatment form, ensuring that it covers the necessary information for a patient to provide informed consent to treatment. The Facility Director will ensure that this form is available to the Intake Coordinator at all times to complete with each patient during the admission process so that they may provide informed consent. The Program Coordinator will then check each chart after the admission process to ensure that it is in the chart and signed by the patient. Random chart checks will be conducted at 3 and 6 months following form has been created to ensure that it is being completed during admission. The Facility Director will create the Consent to Treatment form by 7/31/18 and Clients #6, 7, 8, 3, 4, 11, 12, and 13 will sign the form by 8/15/18. |