INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17 - 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on January 15, 2009.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met the qualifications for the position.
Findings:
Fifteen personnel records were reviewed on December 17, 2008. The facility failed to document that the facility director met the experiential requirements of two years of direct service.
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Plan of Correction
It is the responsibility of the Director of the Division of Substance Abuse Progarms at Thomas Jefferson University to ensure that the position of facility director is occupied by a faculty member whose education and experience are commensurate with the requirements. An up to date curriculum vita for the current Facility Director was presented during the review process and was forwarded to the Department of Health for review on 12/22/08. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met the experiential requirements of the position.
Findings:
Fifteen personnel records were reviewed on December 17, 2008. The facility failed to document that the experiential requirements for the counselor position were met in one of eight personnel records reviewed, #4.
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Plan of Correction
In the future, the Program Coordinator and Associate Division Director will be responsible for assuring that before any counselor assistant is promoted to the status of full-time counselor, that their qualifications are consistent with state regulations. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documents, the facility failed to document an evaluation of the 2007 overall training plan.
Findings:
Administrative documents were reviewed on December 17, 2008. The facility did not document an evaluation of the overall training plan for the 2007 training year.
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Plan of Correction
In December 2008 and continuing annually thereafter the meeting in which the annual training plan is reviewed will be more clearly documented. This review will not only go over what needs have/have not been addressed, but also the overall quality of the training year. The Division Director will be responsible for documenting this review. Each year the Division's Coordinator of Treatment and Training will update the policy and procedure manual for the division; it will contain the current year's overall training plan and a review of the previous year's training plan. This will be done at the start of each year (January 15th). |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed document a written individual training plan which included potential resources for the subject areas for thirteen of thirteen personnel records.
Findings:
Fifteen personnel records were reviewed on December 17, 2007. An individual training plan was required for thirteen client records. The facility failed to document a written individual training plan which included potential resources for the subject areas in thirteen of thirteen personnel records, #1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 13, 14 and 15.
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Plan of Correction
Staff individual training plans completed annually by supervisory staff in conjunction with employees shall in the future specify potential sources of identified trainings (e.g., BHTEN). To assure compliance, the form has been modified to include a prompt that reminds supervisory staff to include this information. This process will be overseen by the Coordinator of Training. |
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.
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Observations
Based on a review of fifteen personnel records, the facility failed to document at least 25 clock hours of training annually for each counselor.
Findings:
Fifteen personnel records were reviewed on December 17, 2008. Documentation of 25 clock hours for the 2007 training year was required in three personnel records. Personnel record #11 documented 20.5 hours of training for the 2007 training year. Personnel record #13 documented 20 hours of training for the 2007 training year.
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Plan of Correction
All evidence of training participation (certificates, program evaluation forms) is collected by the program coordinator and/or senior therapist who promptly forwards this information to the Division's Coordinator of Treatment and Training who monitors the training needs of staff and communicates deficiencies to the Program Coordinator at NARP and Senior Therapist at IOP who are responsible for ensuring that adequate training hours are acquired throughout the year.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document that all personnel were instructed in the use of the fire extinguisher upon staff employment.
Findings:
Fifteen personnel records were reviewed on December 17, 2008. Instruction in the use of the fire extinguisher was required in four personnel records. The facility failed to document that all personnel were instructed in the use of the fire extinguisher upon staff employment in three of four personnel records, #7, 8 and 12.
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Plan of Correction
All Jefferson employees, on their first day of employment, attend a mandatory orientation during which they are taught the proper use of a fire extinguisher and emergency protocol. This information has not been formerly documented in the past. There will now be a form filled out by all new employees that indicates the employee has been properly trained in the use of a fire extinguisher and has been educated in what tasks they are expected to perform during an emergency. Furthermore, all new hires will be trained in the use of program fire extinguishers within one week of commencing employment by either the program coordinator (NARP) or senior therapist (IOP). This documentation will be forwarded to the Coordinator of Training who will place this documentation in the employee's training file.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document that all personnel were trained to perform assigned tasks during emergencies in three of four personnel records.
Findings:
Fifteen personnel records were reviewed on December 17, 2008. Training to perform assigned tasks during emergencies was required in four personnel records. The facility did not document the training to perform assigned tasks during emergencies in personnel records #7, 8 and 12.
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Plan of Correction
Within one week of commencing employment, all new hires (clinical, clerical) will meet with a member of the administrative team (program coordinator at NARP, senior therapist at IOP) who will explain what their assigned tasks are in case of an emergency. Documentation of this training will be placed in the employee's training file. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations completed within 30 days of admission in three of six client records reviewed.
Findings:
Sixteen client records were reviewed on December 18 and 19, 2008. Psychosocial evaluations were required in six client records reviewed. The facility failed to document a psychosocial evaluation in two client records reviewed, #4 and 6. The facility failed to document a psychosocial evaluation within 30 days of admission in client record #5. The client was admitted on 9/23/08 and the psychosocial evaluation was completed on 11/24/08.
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Plan of Correction
To ensure future compliance with this regulation, the associate division director/ facility director and senior therapists (IOP/NARP) will work together to train new as well as existent employees in timely completion of the biopsychosocial. Significance of dating and signing all chart documents will be emphasized. With respect to new employees, during the first three months of employment, all paperwork will be inspected by the program senior therapist before being filed. In addition, senior therapists (NARP & IOP) will examine the charts of all new admissions within 30 days of treatment entry and review them for the presence of a complete evaluation. Should deficiencies be noted, a counselor (new or otherwise) will be given five working days to satisfactorily complete the evaluation. These actions as well as ongoing administrative supervision sessions should prevent such deficiencies in the future. |
711.92(c)(1) LICENSURE TX Plan Goals
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:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short and long-term goals in terms of measurable criteria in three of six client records reviewed.
Findings:
Sixteen client records were reviewed on December 18 and 19, 2008. Short and long-term goals stated in terms of measurable criteria were required in three of six client records reviewed. The facility failed to document treatment plan goals stated in terms of measurable criteria in three of six client records reviewed, #1, 2 and 5.
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Plan of Correction
The Division's Coordinator of Treatment and Training recently undertook, in conjunction with senior therapists at NARP and IOP, a series of training sessions designed to address treatment planning issues. These trainings, in addition to weekly individual supervisory sessions conducted by the senior therapists at both programs (during which treatment plans are regularly reviewed), are expected to result in short and long-term goals formulated by staff and clients that employ measurable/ achievable criteria given the constraints of time. Treatment plans are evaluated via quarterly random sampling of clinical charts conducted by the Division Director, Associate Director, and Coordinator of Treatment & Training. |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in five of six client records reviewed.
Findings:
Sixteen client records were reviewed on December 18 and 19, 2008. Counseling services provided according to the individual treatment and rehabilitation plan were required in six client records. The facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in five of six client records reviewed, #1, 3, 4, 5 and 6. Individual treatment sessions were prescribed as to be provided three times a month in client record #1. The record of services and progress notes documented that individual treatment sessions were scheduled on 11/25/08 and 12/15. Client #1 was admitted on 10/17/08. Group treatment sessions were prescribed as to be provided once per week in client record #3. The record of services and progress notes documented that group treatment sessions were not scheduled between 8/12/08 and 10/31/08. Individual treatment sessions were prescribed as to be provided one time per week in client record #4. The record of services and progress notes documented that individual treatment sessions were scheduled on 9/29, 10/13, 10/30, 11/5, 11/28 and 12/12/08. Individual treatment sessions were prescribed as to be provided once per week in client record #5. The record of services and progress notes documented that individual treatment sessions were scheduled on 11/6, 11/13 and 11/20/08. Client #5 was admitted on 9/23/08. Individual treatment sessions were prescribed as to be provided one time per week in client record #6. The record of services and progress notes documented that individual treatment sessions were scheduled on 9/2, 9/9, 9/16, 12/3 and 12/10/08.
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Plan of Correction
In an effort to assure greater congruence between patient appointment/service expectations cited in the Treatment Plan, and the reality of "no-shows," cancellations, emergencies etc. it is necessary for counseling staff to document in the Progress Note when any of the above (or other untoward events) occur. The division director will review the policy that program staff must document all appointment cancellations, no-shows, and rescheduling. Staff will be reminded of the importance of following through on the counseling recommendations made in treatment plans and, when not doing so, they are expected to document why. If the patient is being non-compliant with prescribed treatment, they must address this issue and provide documentation. If services are to be formally reduced/increased or modified (group or family therapy added) the Treatment Plan should be modified to reflect those changes. Supervisory staff (associate division director/facility director, program coordinator, and senior therapists will use the newly designed "chart log" when monitoring treatment provision, ensuring that psychotherapy is offered as prescribed in treatment plans. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of three client records.
Findings:
Sixteen client records were reviewed on December 18 and 19, 2008. An aftercare plan was required in three client records reviewed. The facility failed to document an aftercare plan in two of three client records reviewed, #13 and 15.
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Plan of Correction
NARP and IOP counseling staff will identify all clients for whom a planned discharge is expected during weekly supervisory sessions conducted by administrative staff (i.e., senior therapists, program coordinators). Once an Aftercare plan has been completed in conjunction with the client, the form will be initialed by either the senior therapist or program coordinator and filed in the chart by the counselor. Ongoing administrative chart review conducted by program administrators (Associate Division Director, Division Director, Program Coordinator, Senior Therapists) will ensure their completion. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
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:
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Observations
Based on a review of client records, the facility failed to include within the informed and voluntary consent forms the right for clients to verbally revoke the consent.
Findings:
Sixteen client records were reviewed on December 18 and 19, 2008. Informed and voluntary consent forms were required in six client records. The consent for release of information form only indicated that the client could revoke the consent in writing in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Changes were made to the most recent versions of the informed and voluntary consent forms to allow for verbal revocation of consent. Upon inspection, it was observed that counselors had older versions of consents stored in their offices. All older versions will be located and destroyed. The most recent consent forms, which permit verbal revocation, will be given to every employee by the Facility Director by January 31, 2009. The senior therapist and program coordinator will
regularly monitor the counselor's paperwork in weekly administrative
supervision to ensure that the correct consent forms are used.
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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 document that the client was notified, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two client records.
Findings:
Sixteen client records were reviewed on December 18 and 19, 2008. Written notification of a decision to involuntarily terminate the client's treatment was required in two client records. The facility failed to document that written notification was provided to the client of a decision to involuntarily terminate the client's treatment in two of two client records reviewed, #7 and 11.
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Plan of Correction
The medical director will not authorize commencement of an involuntary detoxification/ termination unless verification of written notification of the discharge and cause for the dismissal are presented. At this time the medical director will initial the copy of the letter which will be placed in the patient's chart and the involuntary detoxification will commence. |