INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on January 21-23rd, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of nine client records, the facility failed to document a review of the dosage levels at least twice a year in one client record.
Patient #3 was admitted on August 9, 2018 and was still active at the time of inspection. Patient #3 record did not contain any dosage level reviews.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Clinical Supervisor will review appropriate timeframe for dosage reviews with therapists during group supervision. This supervision will include the appropriate timeframe and a requirement for presenting twice yearly dosage checks to the narcotic treatment physician who is responsible for reviewing and signing off on twice yearly dosage checks. These presentations can occur during weekly treatment team meetings with the NTP. All therapists will then self audit charts to ensure documentation is compliant and where it is not compliant, they will complete appropriate documentation. Clinical Supervisor will conduct random quarterly chart audits to ensure continued compliance. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
|
Observations
Based on a review of nine patient records, the facility failed to document the correct number of take-home medications to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
Patient #6 was admitted on January 23, 2015 and was still active at the time of the inspection. The patient was approved for four take home bottles on October 16, 2018. On December 31, 2019 the patient was given five take home bottles and again on January 15, 2020 without documentation of approval for the increase in take home bottles.
Patient #7 was admitted on November 17, 2012 and was discahrged on March 22, 2019. The patient was approved for five take home bottles on December 10, 2014. The patient was given six take home bottles starting in November 2019 without documentation of approval for the increase in take home bottles.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Clinical Supervisor will review appropriate timeframe for take home bottle applications with therapists during group supervision. All therapists will then self audit charts to ensure documentation is compliant and where it is not compliant, they will complete appropriate documentation. Clinical Supervisor will conduct random quarterly chart audits to ensure continued compliance. Regarding patient #6 and take home bottles on 12/31/19 and 1/15/2020, these dates both included holiday take home bottles. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
|
Observations
Based on a review of nine patient records, the facility failed to complete and document a case consultation every 90 days as specified in the policy and procedure manual in three client records.
Patient #5 was admitted on August 11, 2016 and was still active at the time of the inspection. The patient record indicated that case consults were being completed yearly instead of quarterly.
Patient #6 was admitted on January 23, 2015 and was still active at the time of inspection. The patient record indicated that case consults were being completed yearly instead of quarterly.
Patient #7 was admitted on November 17, 2012 and was discharged on March 22, 2019. The patient record indicated that case consults were being completed yearly instead of quarterly.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Policy and procedures manual will be updated by the Program Director to reflect case consultations are due quarterly during the first year of admission and then annually thereafter. |
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.
|
Observations
Based on a review of nine patient records, the facility failed to ensure that all patients received an annual evaluation.
Patient #3 was admitted on August 9, 2018 and was still active at the time of the inspection. The patient was due to have an annual evaluation by August 9, 2019 but did not receive an annual evaluation.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Clinical Supervisor will review appropriate timeframe for annual evaluations with therapists during group supervision. All therapists will then self audit charts to ensure documentation is compliant and where it is not compliant, they will complete appropriate documentation. Clinical Supervisor will conduct random quarterly chart audits to ensure continued compliance. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
|
Observations
Based on a review of nine client records, the facility failed to ensure that all clients received a comprehensive treatment plan.
Patient #3 was readmitted on November 11, 2019 and was discharged on January 10, 2020. A compressive treatment plan was to be completed within 30 dates of admission, however no comprehensive treatment plan was completed.
These findings were discussed with the facility staff during the inspection process.
|
Plan of Correction
Clinical Supervisor will review appropriate timeframe for comprehensive treatment plans with therapists during group supervision. All therapists will then self audit charts to ensure documentation is compliant and where it is not compliant, they will complete appropriate documentation. Clinical Supervisor will conduct random quarterly chart audits to ensure continued compliance. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to include both a policy and procedure for the following unusual incidents: physical assault by a patient, inappropriate behavior by a patient causing disruption to the narcotic treatment program, selling of drugs on the premises, complaints of patient abuse, death or serious injury due to trauma, suicide, medication error or unusual circumstances, Significant disruption of services due to disaster such as fire, storm, flood or other occurrence. Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
Theses findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Policy and procedure manual will be updated to include the following regarding unusual incidents: Physical assault by a patient, inappropriate behavior by a patient causing disruption to the narcotic treatment program, selling of drugs on the premises, complaints of patient abuse, death or serious injury due to trauma, suicide, medication error or unusual circumstances, significant disruption of services due to disaster such as fire, storm, flood or other occurrence, incident with potential for negative community reaction or which the facility director believes may lead to community concern. |
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.
|
Observations
Based on a review of nine patient records, the facility failed to document treatment plan updates within the regulatory timeframe in three patient records reviewed.
Patient #4 was admitted on September 3, 20119 and was still active at the time of the inspection. The comprehensive treatment plan was completed on September 15, 2019 and the next update was due no later than November 15, 2019; however, there was no update documented in the record at the time of the inspection.
Patient #5 was admitted on August 11, 2016 and was still active at the time of the inspection. A treatment plan update was completed on September 4, 2019 and the next update was due no later than November 4, 2019; however, there was no update documented in the record until December 4, 2019.
Patient #6 was admitted on January 23, 2015 and was still active at the time of the inspection. A treatment plan update was completed on June 27, 2019 and the next update was due no later than August 27, 2019; however, there was no update documented in the record until September 10, 2019.
These findings were discussed with facility staff at the time of inspection
|
Plan of Correction
Clinical Supervisor will review appropriate timeframe for updated treatment plans with therapists during group supervision. All therapists will then self audit charts to ensure documentation is compliant and where it is not compliant, they will complete appropriate documentation. Each therapist will be asked to create a tracking system to ensure deadlines are met. This tracking system can be reviewed in individual supervision with Clinical Supervisor if needed. When patients are non-compliant or not attending treatment sessions, therapist will document this for the chart and complete the treatment plan as quickly as possible. Clinical Supervisor will conduct random quarterly chart audits to ensure continued compliance. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
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:
(iii) The purpose of disclosure.
|
Observations
Based on a review of patient records, the facility failed to document the purpose of the disclosure in one patient record.
Patient #2 was admitted on August 11, 2016 and was still active at the time of the inspection. A consent to an outside provider was signed and dated on August 20, 2019 that failed to include the purpose of the disclosure.
These findings were discussed with the facility staff during the inspection process.
|
Plan of Correction
Clinical Supervisor will review all aspects of consent forms with necessary staff to ensure that all components are completed. Clinical Supervisor will review with necessary staff during group supervision. Therapists will be responsible for auditing their own charts to ensure that all required sections are completed on consent forms. Therapists will also be responsible to complete new consents for consents that are not completed properly. Clinical Supervisor will conduct random chart inspections ongoing to ensure all aspects of consent forms are completed. |