INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15-16, 2013 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.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Report" for the two facility's that make up the Project was reviewed. The "Staffing Requirements Facility Summary Reports" completed by the facility's on January 9, 2013 and January 16, 2013 listed a combined total of 18 counselors, 2 lead counselors, and 1 Facility Director/counselor who was providing drug and alcohol counseling. The total number of drug and alcohol counseling hours per week provided by the Project equates to 25 FTE counselors within the Project, and therefore the project is required to have at least 3 full-time clinical supervisors. The "Staffing Requirements Facility Summary Reports" did not identify a full-time clinical supervisor at either of the Project's two facility's.
The findings were reviewed with the Facility Director during the inspection and at the exit interview on January 16, 2013. However, during the inspection the Facility Director disputed the findings, but was not able to provide further documentation.
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Plan of Correction
The project employs the equivalent of 17 FTE clinicians (11 at NARP, 4.5 at IOP, and 1.5 at the Outreach Program). Therefore, to meet the standard of one full-time supervisor per eight counselors, a total of two full-time clinical supervisors would be needed. To ensure compliance, we will ensure that the two current clinical supervisor's caseloads do not exceed five patients at any time. In addition, we are in the process of filling a supervisory position that became vacant following an unexpected death. It is anticipated that following recruitment that this position will be filled by April 15, 2013. It shall be the responsibility of the Facility Director to ensure that the Division's ongoing compliance. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observations on January 16, 2013, the facility failed to light interior exits and stairs at all times.
The findings include:
A physical plant inspection was conducted on January 16, 2013. Areas of the rear interior emergency exit stairs on the second floor of the facility leading to Washington Avenue Street were not lighted during the physical plant inspection. This condition was observed at approximately 10:36 A.M.
The findings were confirmed during an interview with one of the counselors at approximately 10:37 A.M.
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Plan of Correction
The Facility Director and his designees shall inspect the rear emergency stairwell on a monthly basis to ensure compliance with the regulation regarding satisfactory lighting of all interior exits. To aid in maintaining compliance with the regulation, long-lasting flourescent bulbs will be used in the light fixture going forward. This plan was enacted immediately following the 2013 licensing visit. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on January 15, 2013. The records were reviewed from the period covering September 2012 to December 2012. In all the months reviewed, the facility did not document whether the fire alarm or smoke detector was operative.
The findings were confirmed during an interview with facility director at approximately
10:50 A.M.
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Plan of Correction
The fire drill record has been modified to include documentation of the functioinal status of the smoke detector system. It shall be the responsibility of the Program Coordinator to ensure that the smoke detector system is tested on a monthly basis and that the results are recorded. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to provide documentation that they set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were reviewed on January 15, 2013. The records were reviewed from the period covering September 2012 to December 2012. In all the months reviewed, the facility did not document whether or not they set off a fire alarm or smoke detector during each fire drill.
The findings were confirmed during an interview with facility director at approximately
10:50 A.M.
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Plan of Correction
The fire drill record has been modified to include doumentation that the smoke detector system was set off during monthly fire drills. It shall be the responsibility of the Program Coordinator to document on the monthly fire drill log that the smoke detector system was activated (and functioned appropriately). |