INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on January 10, 2023 through January 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction documenting that each patient shall receive an average of 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotherapy were submitted and approved by the Department for the February 24, 2021 and December 1, 2021 through December 2, 2021 annual licensing inspections. Failing to document that each patient shall receive an average of 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotherapy was again found to be a deficiency in the January 10, 2023 through January 11, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to staff turn over, Clinic Director will again review regulations with counselors during group supervision on 2/6/23. This will include reviewing scheduling of reoccurring appointments in EHR, documenting when individuals do not show in EHR, and rescheduling when necessary.
Clinic Director will address psychotherapy hours in individual sessions with counselors who are out of compliance and support them in implementing appropriate interventions.
Clinic Director will randomly complete chart audits to ensure psychotherapy hours are in compliance. |
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 patient records, the facility failed to ensure that a narcotic treatment physician reviewed dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient's therapeutic dosage in two of seven patient records reviewed.Patient #1 was admitted July 6, 2017 and was active at the time of inspection. There was no documentation of a physician dosage review in the record during the reviewed timeframe.Patient #2 was admitted March 1, 2021 and was active at the time of inspection. There was no documentation of a physician dosage review in the record during the reviewed timeframe.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We are continuing to work to have our EHR track and alert us when this is due. In the interim of getting this feature workings, we will implement the following plan of correction. Lead LPN Nurse will meet with all individuals who receive methadone at Family Center quarterly. During this meeting, Lead LPN will review with individuals their dose and any changes that are needed if applicable. Lead LPN Nurse will complete documentation of dose review and present it to the medical director or designee for review. Nurse Coordinator will be responsible for completing random chart audits to ensure this is being done and documented appropriately |
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 patient records, the narcotic treatment program failed to document that each patient received an average of 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotherapy, in one of five applicable patient records reviewed. Patient #2 was admitted March 1, 2021 and was active at the time of inspection. There was no documentation in the record indicating there were any individual psychotherapy hours provided to the patient during the months of October, November, and December 2022.This is a repeat citation from the February 24, 2021 and December 1, 2021 through December 2, 2021 annual licensing renewal inspections. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to staff turn over, Clinic Director will again review regulations with counselors during group supervision on 2/6/23. This will include reviewing scheduling of reoccurring appointments in EHR, documenting when individuals do not show in EHR, and rescheduling when necessary.
Clinic Director will address psychotherapy hours in individual sessions with counselors who are out of compliance and support them in implementing appropriate interventions.
Clinic Director will randomly complete chart audits to ensure psychotherapy hours are in compliance. |
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 patient records, the narcotic treatment program failed to document the results of an annual physical examination, which is given by the narcotic treatment program and includes an annual reevaluation by the narcotic treatment physician, in three of five applicable patient records reviewed.Patient #1 was admitted July 6, 2017 and was active at the time of inspection. The last documented physical exam was completed on March 2, 2021.Patient #2 was admitted March 1, 2021 and was active at the time of inspection. The last documented physical exam was completed on March 1, 2021.Patient #7 was admitted March 26, 2021 and was discharged November 20, 2022. The last documented physical exam was completed on March 29, 2021.This is a repeat citation from the December 1, 2021 through December 2, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We are continuing to work to have our EHR track and alert us when this is due. In the interim of getting this feature workings, we will implement the following plan of correction. Lead LPN Nurse will track dates of all last physicals for all individuals enrolled at Family Center. The Lead LPN will be responsible for scheduling individuals for their physical exam with a member of the medical team. Individuals will receive reminder notifications when they check in for medication beginning the week prior to their appointment thru the day of their appointment. The Lead LPN will be responsible for following up to ensure that the individual attended their appointment and will reschedule appointments when necessary. Nurse Coordinator will review the tracking sheet quarterly and select random charts to audit to ensure that physicals are being completed within the timeframe. |
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 patient records, the narcotic treatment program failed to document, in the record, an aftercare plan in one of one applicable patient records reviewed. Client #4 was admitted on June 2, 2022 and was discharged on July 19, 2022. There was no documentation of an aftercare plan at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In group supervision on 2/6/2023, Counselors will receive a training on required documentation for discharges including when to complete an aftercare plan. The Clinic Director will lead this training. Counselors will have the opportunity to ask questions. The training will be documented in their training file.
Clinic Director will audit all charts upon discharge for missing documentation and corrections will be made prior to discharge when possible. |
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 patient records, the narcotic treatment program failed to document, in the record, a discharge summary in one of four applicable patient records reviewed. Client #4 was admitted on June 2, 2022 and was discharged on July 19, 2022. There was no documentation of a discharge summary at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In group supervision on 2/6/2023, Counselors will receive a training on required documentation for discharges including when to complete a discharge summary. The Clinic Director will lead this training. Counselors will have the opportunity to ask questions. The training will be documented in their training file.
Clinic Director will audit all charts upon discharge for missing documentation and corrections will be made prior to discharge when possible. |
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 patient records, the narcotic treatment program failed to document, in the record, an annual evaluation of each patient's status completed by the patient ' s counselor and reviewed, dated, and signed by the medical director in two of four applicable patient records reviewed. Patient #2 was admitted March 1, 2021 and was active at the time of inspection. The last annual clinical evaluation was completed on March 8, 2021.Patient #7 was admitted March 1, 2021 and was discharged November 20, 2022. The last annual clinical evaluation was completed on September 14, 2021.This is a repeat citation from the December 1, 2021 through December 2, 2021 annual licensing renewal inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
During group supervision on 2/6/23, Clinic Director will review the requirements of documentation requirements for annual evaluations.
Clinic Director will review in individual supervision when necessary.
Clinic Director will randomly complete chart audits to ensure documentation is being completed. |
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 client records, the facility failed to ensure that treatment plans were reviewed and updated at least every 60 days in four of seven client records reviewed.Client #1 was admitted July 6, 2017 and was active at the time of inspection. A treatment plan update was completed on August 29, 2022 and the next update was due no later than October 29, 20221. However, the update was completed on December 16, 2022.Client #2 was admitted March 1, 2021 and was active at the time of inspection. A treatment plan update was completed on August 11, 2022 and the next update was due no later than October 11, 2022. However, the update was not completed as of the date of the inspection.Client #6 was admitted May 20, 2020 and was discharged March 12, 2022. A treatment plan update was completed on January 21, 2022 and the next update was due no later than March 21, 2022. However, the update was not completed prior to the client ' s discharge.Client #7 was admitted March 26, 2021 and was discharged November 20, 2022. A treatment plan update was completed on May 25, 2022 and the next update was due no later than July 25, 2022. However, the update was completed on September 12, 2022.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We are continuing to work to have our EHR track and alert us when this is due. In the interim of getting this feature workings, we will implement the following plan of correction.
Clinic Director will conduct an audit of all charts through a report and will meet with counselors during individual supervision to review all outstanding treatment plans. Clinic Director will review requirements of treatment plans and develop individual plans to support counselors in completing documentation within the time frame.
Clinic Director will continue to utilize the EHR report system to ensure documentation is completed within the time frame. |
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client record reviewed.Client # 7 was admitted on March 26, 2021 and was administratively discharged on November 20, 2022. There was no documentation in the record indicating that the client was notified of the facility's decision to involuntarily terminate the client's treatment at the project.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In group supervision on 2/6/2023, Counselors will receive a training on required documentation for discharges including when to complete a termination letter. The Clinic Director will lead this training. Counselors will have the opportunity to ask questions. The training will be documented in their training file.
Clinic Director will audit all charts upon discharge for missing documentation and corrections will be made prior to discharge when possible. Additionally, this document has been updated to include the method of delivery of the notification letter of termination. |
711.96(b) LICENSURE Appeal of Termination
711.96. Notification of termination.
(b) The client shall have the opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.Client # 7 was admitted on March 26, 2021 and was administratively discharged on November 20, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/6/23 in group supervision, Clinic Director will review client's right to appeal decisions for administrative discharges. This is included in the discharge letter that must be completed with all administrative discharges.
Clinic Director will review all administrative discharges to ensure that the client is being offered the opportunity to appeal. |