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 16 - 17, 2015 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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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a wall mirror in each bathroom.
The findings include:
A physical plant inspection was conducted on December 17, 2015.
The facility was required to provide a wall mirror in each bathroom. The facility failed to provide a wall mirror in the patient bathroom on the second floor.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A wall mirror has been ordered and should arrive by 1/27/16. The wall mirror will be secured to the wall in the needed bathroom. The Administrative Assistant will ensure this mirror remains in place during the monthly building checks of lights and fire extinguishers. The Clinical Supervisor will additionally check this on a quarterly basis to ensure the mirror is still in place and replace as needed. |
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 facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years.
The findings include:
Eight patient records were reviewed on December 17, 2015, to ensure the facility provided at least 2.5 hours of psychotherapy during the patient's first 2 years in treatment. The facility failed to provide 2.5 hours of psychotherapy per month for patient, # 1, 4, and 8.
Patient # 1 was admitted to the program on March 7, 2015. The facility failed to provide an average of 2.5 hours of psychotherapy per month for patient # 1 for the following months; July 2015, August 2015, October 2015 and November 2015.
Patient # 4 was admitted to the program on March 23, 2015. The facility failed to provide an average of 2.5 hours of psychotherapy per month for patient # 4 for the month August 2015.
Patient # 8 was admitted to the program on April 25, 2015. The facility failed to provide an average of 2.5 hours of psychotherapy per month for patient # 8 for the month August 2015.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
For patient's #1 and #4, the assigned counselor left in August with no notice. This left these two patients receiving under the 2.5 hour requirement.
Counselors will develop a tracking system for each individual caseload to ensure the minimum hours are being acheived. The Clinical Supervisor will periodly conduct random chart audits to ensure patients are meeting the minimum hours. We will continue to contract non-compliant individuals who are not meeting the minimum requirement (which was done with all three patients noted in the citation). Additionally we will continue to complete document disclaimers for the chart indicating we are aware of the deficiency. Continued non-compliance will result in a higher level of care (HLOC) referal or discharge for non-pregnant individuals who are not willing to go to a HLOC.
The Clinical Supervisor will be ultimately responsible to ensure the minimum hours of treatment are being acheived and will review any deficiencies with counselor during individual supervision. Additionally, group supervision will be utilized to identify effective ways of achieving the minimum hour requirement. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a physical plant inspection, the facility failed to secure patient records within locked storage containers and maintain the confidentiality of patient identity and records.
The findings include:
A physical plant inspection was conducted on December 17, 2015. The facility failed to secure patient records within locked file cabinets.
The facility failed to ensure that patient records were maintained within locked file cabinets in what was identified as the chart room; however, this room was a multi-purpose room as the room had a conference table with chairs, a water cooler, coffee maker and a microwave.
During the physical plant inspection patient records were observed in unlocked file cabinets, current filing was placed in boxes on top of the file cabinet, and discharged records were placed all around the room on top of the file cabinets; there were loose patient charts and boxes of patient charts covered with a sheet.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Family Center currently utilizes a double locking system ensuring that charts are stored behind two locked doors. In addition, all charts will be stored in locked file cabinets. The Clinical Supervisor/Clinic Director will ensure this plan of correction is implemented.
All file cabinets have had keys made when possible and if not possible, a locking mechanisms will be installed on the cabinets allowing for a key padlock to be utilized. Additional storage space will be provided to ensure all on-site closed charts are able to be in locked cabinets and no longer placed on top of file cabinets. The documents waiting to be filed will also be stored in a locked cabinets. The Administrative Intake Coordinator and Clinical Supervisor/Clinic Director will have keys to all file cabinets. |
711.94(b) LICENSURE Display Hours of Operation
711.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of operation to the general public.
The findings include:
A physical plant inspection was conducted on December 17, 2015. The facility failed to display the project's hours of operation to the general public.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program has requested an exception for this regulation which was submitted on January 26, 2016. However if the exception is not granted the following will occur:
The hours of operation will be displayed outside the clinic door on the 2nd floor. A sign indicating with will be secured to the wall. The Clinical Supervisor will be responsible for ensuring this remains posted by checking quarterly. |
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 a physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes.
The findings include:
A physical plant inspection was conducted on December 17, 2015.
The facility failed to display an emergency telephone number to the general public.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program has requested an exception for this regulation which was submitted on January 26, 2016. However if the exception is not granted the following will occur:
The emergency telephone number will be displayed outside the clinic door on the 2nd floor. A sign indicating this information with will be secured to the wall. The Clinical Supervisor will be responsible for ensuring this remains posted by checking quarterly.
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