INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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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711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the project failed to follow their written procedures for the management of treatment/rehabilitation services in five of five applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plans are to be completed within 30 days of admission. Additionally, the facility policy and procedure manual stated that the medical, drug and alcohol, and personal histories, as well as psychosocial evaluations, are to be completed within 30 days of admission.
Client # 2 was admitted on September 26, 2024 and was active at the time of inspection. The medical, drug and alcohol, personal histories, and the psychosocial evaluation were due to be completed no later than October 26, 2024; however, the histories and evaluation were completed on November 12, 2024.
Client # 3 was admitted on August 15, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed no later than September 15, 2024; however, the plan was completed on October 21, 2024.
Client # 4 was admitted on September 26, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed no later than October 26, 2024; however, the plan was completed on November 14, 2024. Additionally, the medical, drug and alcohol, personal histories, and the psychosocial evaluation were due to be completed no later than October 26, 2024; however, the histories and evaluation were completed on November 12, 2024.
Client # 5 was admitted on August 29, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by September 29, 2024; however, the plan was completed on October 21, 2024. Additionally, the medical, drug and alcohol, personal histories, and the psychosocial evaluation were due to be completed no later than September 29, 2024; however, the histories and evaluation were completed on November 12, 2024.
Client # 6 was admitted on August 29, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by September 29, 2024; however, the plan was completed on November 4, 2024. Additionally, the medical, drug and alcohol, personal histories, and the psychosocial evaluation were due to be completed no later than September 29, 2024; however, the histories and evaluation were completed on November 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Thomas Jefferson University Outreach program transitioned from paper charts to electronic health record (EHR) in July of 2025. Citation was received for treatment plans and the biopsychosocial assessments for the client charts reviewed were not completed within the first 30 days. A plan of correction was developed on 11/22/2024 by the TJU Outreach Executive Director and Clinical Supervisor to correct this deficiency and prevent it from happening in the future. The executive director made an adjustment to settings in the current EHR to create an automatic scheduling feature for all treatment plans and biopsychosocial assessments to be completed within 30 days of the client's admission date. This automatic scheduling feature will provide an alert reminder to the Outreach counselor when the treatment plan and biopsychosocial assessments are due. The alert will provide a reminder message starting 7 days out from the due date and continue daily until tasks are completed. This will aim to prevent the treatment plan and biopsychosocial assessments from being completed more than 30 days from admission. The Outreach clinical supervisor will provide additional training to the Outreach counselor on the DDAP regulations for timely completion of documentation and provide oversight of the counselor's documentation on a regular basis to ensure compliance through weekly chart audits. If there are any issues during the audit process, then the clinical supervisor will bring it to the attention of the Outreach counselor and rectify the situation before becoming a compliance issue in the future. The training will occur by 12/31/2024. The executive director will oversee compliance through additional chart audits and supervision meetings with the clinical supervisor.
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711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the client's comprehensive treatment plan in four of five applicable client records reviewed.
Client # 3 was admitted on August 15, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan, completed on October 21, 2024, did not include written documentation of the type and frequency of services.
Client # 4 was admitted on September 26, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan, completed on November 14, 2024, did not include written documentation of the type and frequency of services.
Client # 5 was admitted on August 29, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan, completed on October 21, 2024, did not include written documentation of the type and frequency of services.
Client # 6 was admitted on August 29, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan, completed on November 4, 2024, did not include written documentation of the type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Thomas Jefferson University Outreach program transitioned from paper charts to electronic health record (EHR) in July of 2025. Citation was received for treatment plans not including the type of treatment and the frequency of treatment. A plan of correction was developed on 12/12/2024 by the TJU Outreach Executive Director and Clinical Supervisor to correct this deficiency and prevent it from happening in the future. The Outreach Counselor will make an addendum to the patient treatment plans to include information about the type of intervention and frequency of treatment for the interventions on the treatment plan. This will be completed by 12/22/2024 and the Outreach Clinical Supervisor will review the treatment plans by 12/23/2024 and ensure that the type and frequency information is on the current treatment plans. To prevent this citation form occurring in the future, the Executive Director made an adjustment in the EHR to include an area on the treatment plan for the Outreach Counselor to indicate the type of treatment to include a selection of individual and/or group psychotherapy intervention and an area to add the frequency of treatment for the interventions on the treatment plan. This was completed on 12/12/2024 so that any treatment plans created or updated after 12/12/2024 in the EHR will prompt the counselor to enter the type and frequency. Lastly, the Outreach Clinical Supervisor staff will train the Outreach Counselor on completing treatment plans in the EHR including focus on noting the type and frequency information. The training will occur by 12/31/2024. The clinical supervisor will monitor compliance through weekly chart audits. The executive director will oversee compliance through additional chart audits and supervision meetings with the clinical supervisor. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to include the name of the person, agency, or organization to whom the disclosure was to be made to on a consent to release information form in two of six client records reviewed.
Client # 3 was admitted on August 15, 2024 and was active at the time of inspection. A release of information form to an emergency contact was signed and dated by the client on August 15, 2024, but the consent form did not include the name of the person to whom the disclosure was to be made.
Client # 5 was admitted on August 29, 2024 and was active at the time of inspection. A consent form to an emergency contact was signed and dated by the client on August 29, 2024, but the consent form did not include the name of the person to whom the disclosure was to be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Thomas Jefferson University Outreach program transitioned from paper charts to electronic health record (EHR) in July of 2025. Citation was received for an emergency contact release of information not including the name of the person with whom the disclosure was to be made. A plan of correction was developed on 12/12/2024 by the TJU Outreach Executive Director and Clinical Supervisor to correct this deficiency and prevent it from happening in the future. The Outreach Counselor will complete a new emergency contact release of information for active clients to include the name of the person with whom the disclosure was to be made to make that form complete in its entirety. This will be completed by 12/31/2024 and the Outreach Clinical Supervisor will review the emergency contact release of information by 12/31/2024 and ensure that it is completed in its entirety with the name of the person with whom the disclosure was to be made. To prevent this citation from occurring in the future, the executive director made an adjustment in the EHR on 12/12/2024 so that all Releases of Information forms including the Emergency Contact have required fields to ensure that the staff are prompted to complete all areas that are required before a form can be considered finalized. The staff will receive a message stating form was incomplete for an area and asked to complete it before finalizing it. This will prevent the required information from being missed on these forms. The clinical supervisor will monitor compliance through weekly chart audits. The executive director will oversee compliance through additional chart audits and supervision meetings with the clinical supervisor. The Outreach clinical supervisor will provide training to the Outreach counselor on the importance of completing all required fields on releases of information to comply with state regulations and how the new EHR requirement fields will help prevent something from being missed in the future. The training will occur by 12/31/2024. |
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.
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Observations
Based on a review of client records, the facility failed to include the specific information to be disclosed on consent to release information forms in six of six client records reviewed.
There were treatment, payment, and healthcare operations (TPO) consent to release information forms, with eight entities, documented in every client record reviewed. Each TPO consent to release information form in every record reviewed was missing documentation of the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Thomas Jefferson University Outreach program transitioned from paper charts to electronic health record (EHR) in July of 2025. Citation was received for missing the type of information to be disclosed to the multiple entities on a release of information. A plan of correction was developed on 12/12/2024 by the TJU Outreach Executive Director and Clinical Supervisor to correct this deficiency and prevent it from happening in the future. The Outreach Counselor will complete a new multiple entities release of information for active clients to include the type of disclosures to be made to those entities. This will be completed by 12/31/2024 and the Outreach Clinical Supervisor will review the multiple entities release of information by 12/31/2024 and ensure that it is completed in its entirety with the disclosure information. To prevent this citation from occurring in the future, the executive director made an adjustment in the EHR on 12/12/2024 so that all the release of information for multiple entities were updated in the EHR to include the type of disclosure of information that would be made for each entity in order to remain compliant with the regulations. The clinical supervisor will monitor compliance through weekly chart audits. The executive director will oversee compliance through additional chart audits and supervision meetings with the clinical supervisor. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in one of six client records reviewed.
Client #4 was admitted on September 26, 2024 and was still active at the time of the inspection. A consent to release information form to multiple entities was signed by the client on September 26, 2024; however, there was no documentation indicating a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Thomas Jefferson University Outreach program transitioned from paper charts to electronic health record (EHR) in July of 2025. Citation was received for a consent form that did not include whether a copy was offered to the client. A plan of correction was developed on 12/12/2024 by the TJU Outreach Executive Director and Clinical Supervisor to correct this deficiency and prevent it from happening in the future. The Outreach Counselor will complete an addendum to the release of information for active clients that had the missing information about whether a copy was accepted or not by a client. This will be completed by 12/31/2024 and the Outreach Clinical Supervisor will review the release of information by 12/31/2024 and ensure that it is completed in its entirety on whether the patient accepted a copy of the form or not. To prevent this citation from occurring in the future, the executive director made an adjustment in the EHR on 12/12/2024 so that all Releases of Information and Consent forms will have the required field stating was a copy accepted by a client and marked in the EHR to ensure that the staff are prompted to complete all areas that are required before a form can be considered finalized. The staff will receive a message stating form was incomplete for an area and asked to complete it before finalizing it. The clinical supervisor will monitor compliance through weekly chart audits. The executive director will oversee compliance through additional chart audits and supervision meetings with the clinical supervisor. The Outreach clinical supervisor will provide training to the Outreach counselor on the importance of completing all required fields on releases of information to comply with state regulations and how the new EHR requirement fields will help prevent something from being missed in the future. The training will occur by 12/31/2024. |