INITIAL COMMENTS
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| This report is a result of an on-site licensure renewal inspection conducted on |
Plan of Correction
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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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #3 and #4's employee record.
Employee #3 was hired as a counselor on June 8, 2015 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2017 through December 31, 2017. Employee #3's employee record only documented 19.45 hours of annual training for the training year reviewed.
Employee #4 was hired as a counselor on August 12, 2002 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2017 through December 31, 2017. Employee #4's employee record only documented 24 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will work with Administrative Assistant(s) to ensure all employees are on track to complete training hours each calendar year aligning with the DDAP regulation.
In October of each year, an employee chart audit will be completed to ensure that each employee is going to meet the required training hours. Administrative Assistant(s) will ensure that all tracking of trainings is complete and filed appropriately to ensure accurate documentation of annual training completion. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on May 21-22, 2018, it was observed that the facility failed to ensure that there were no heaters that were not permanently mounted or installed in the child play area on the second floor.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employees will be reminded by supervisors of the regulation and not being permitted to have heaters on site. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide protective caps over each electrical outlet.
The family group room on the administrative floor lacked protective caps for all of the electrical outlets.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Protective caps will be placed in all unused electrical outlets.
Administrative Assistant will check weekly to ensure that these caps are in place. Additionally group facilitators will check group rooms prior to children entering the room and request protective caps when needed. |
715.9(a)(3) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
Based on a review of patients records on May 21-22, 2018, the facility failed to document a drug use history and the current drug use status in patient records #15, 19, and 22.
Patient #15 was admitted on 09/20/17 and discharged 12/29/17. There was no documentation of a drug use history and the current drug use status in the patient record.
Patient #19 was admitted on 04/04/18 and discharged 05/15/18. There was no documentation of a drug use history and the current drug use status in the patient record.
Patient # 22 was admitted on 12/11/17 and discharged 05/15/18. There was no documentation of a drug use history and the current drug use status in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review current intake paperwork ensuring that there is space to document drug use history and current drug use status.
Supervisors will work with individuals completing intake to ensure that this information is accurately and completely filled out upon admission. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records on May 21-22, 2018, the facility failed to document a face to face contact with the physician and patient # 18.
Patient # 18 was admitted on 02/14/17 and discharged 10/19/17. There was no documentation of a face to face contact in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors will ensure that intake staff are aware of this regulation and able to ensure admissions coming from Thomas Jefferson University Hospital (TJUH) have a completed face-to-face with a physician prior to admission to Family Center. Nursing supervisor will ensure that all documentation during hospital stay is printed and noted in the clinic medical chart.
For any on-site inductions, individuals will meet with the medical director prior to induction and the face-to-face will be noted on their psychiatric evaluation. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on a review of client records on May 21-22, 2018, the facility failed to provide documentation of prenatal support or care for client # 20 in the client record.
Client # 20 was admitted on 01/30/2018 and was still an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will continue to schedule and follow up with individuals regarding their prenatal care appointments at Jefferson Obstetrics and Gynecology Associates. When individuals are struggling to attend appointments, nursing staff will work in conjunction with therapist to best support the individual in attending appointments and utilize treatment planning goals. Individuals will continued to be reminded of all prenatal appointments upon check-in for medication. |
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 on May 21-22, 2018, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, of which 1 hour shall be individual psychotherapy in patient records #8, 10, and 11.
Patient # 8 was admitted on 08/05/16 and was still an active client at the time of the inspection. The patient record lacked documentation for 1 hour of individual therapy during the month of January 2018.
Patient # 10 was admitted on 04/26/16 and was still an active client at the time of the inspection. The patient record lacked documentation of any individual sessions during the month of March 2018.
Patient # 11 was admitted 05/20/17 and was still an active client at the time of the inspection. The patient record lacked documentation any individual session during the month of June 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For individuals struggling with compliance, therapists will work with these individuals to set treatment plan goals and develop behavioral contracts in hopes of assisting in behavior change. These steps will be utilized in an effort to decrease the number of individuals discharged for non-compliance due to the current state with the opioid crisis. However, when needed, individuals may be discharged due to non-compliance.
Additionally, therapists will continue to utilize "hold" (a tool utilized to assist individuals with being compliant with treatment sessions/groups) for individuals experiencing barriers to attending individual sessions. "Hold" stops the person from being able to medicate immediately and they must speak with the staff member who utilized this tool before being medicated. Therapists will track hours and utilize supervision to explore barriers to achieving the required hours of monthly psychotherapy for each individual on their caseload.
Clinical Supervisor will conduct random chart audits to ensure that individuals are meeting the required hours of monthly psychotherapy. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a record review conducted on May 21-22, 2018 for a patient that was transferred to another program, the facility failed to document what paperwork had been sent to the receiving facility.
Patient # 13 was admitted on 09/20/15 and was transferred on 12/12/17. There was no documentation of the paperwork sent to the receiving facility in in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director updated fax/scan cover sheets for transferring individuals to other programs. Program Director will provide a memo to staff including this updated cover sheet to be used with all future transfers. Staff will receive the memo regarding this regulation and including all transfer paperwork transmissions in the clinical chart. |
715.23(b) LICENSURE Patient records
(b) Each patient file shall include the following information:
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Observations
Based on a review of patient records on May 21-22, 2018, the facility failed to document a complete personal history, drug and alcohol history, and medical history in patient records # 15, 19, and 22.
Client # 15 was admitted on 09/20/17 and was discharged on 12/29/17. There was no documented personal history, drug and alcohol history, and medical history in the patient record.
Client # 19 was admitted on 04/04/18 and was discharged on 05/15/18. There was no documented personal history, drug and alcohol history, and medical history in the patient record.
Client # 22 was admitted on 12/11/2017 and was discharged on 05/15/18. There was no documented personal history, drug and alcohol history, and medical history in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors will ensure that intake paperwork (including personal substance use history and medical history) are completed upon intake and pulled from Thomas Jefferson University Hospital when necessary to be included in intake. Additionally, this information will again be reviewed during the Biopsychosocial and Initial Psychiatric Evaluation.
During random chart audits, supervisors will ensure this information is complete in each chart. When information is unable to be completed due to non-compliance, staff will document the non-compliance but continue to work to complete necessary documentation. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records on May 21-22, 2018, the facility failed to document annual physical exams in patient records #8 and 17.
Patient # 8 was admitted on 05/05/16 and discharged on 04/27/18. An annual physical exam was due on 05/05/17.
Patient # 17 was admitted on 07/12/16 and was discharged on 12/08/17. An annual physical exam was due on 07/12/17.
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Plan of Correction
Nursing staff will review their tracking system to ensure that all patients are being tracked for annual physical exams. Nursing staff will continue to meet with individuals who are in need of this appointment, assist in scheduling when possible, and as a last resort schedule the individual to meet with the Medical Director for completion of annual physicals.
For individuals missing documentation in their charts during the audit, the documentation has been placed in their charts as of this time. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of Patient records on May 21-22, 2018, the facility failed to document a discharge summary in Patient record #16.
Patient # 16 was admitted on 07/14/17 and never returned for treatment. There is no documentation of a discharge, discharge summary, or a follow up in the Patient records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will follow up with therapists regarding the missing discharge paperwork and have the paperwork completed no later than 7/31/18.
Clinical Supervisor and Lead therapist will develop a plan for ensuring all discharge documentation is received timely and filed in the chart and the chart is audited before charts are closed. |
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.
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Observations
Based on a review of Patient records on May 21-22, 2018, the facility failed to document annual evaluations in patient records # 7, 8, and 11.
Patient #7 was admitted on 08/14/16 and was an active patient at the time of the inspection. An annual evaluation was dated on 05/14/18 and one was not documented at admission.
Patient # 8 was admitted on 08/05/16 and was an active patient at the time of the inspection. The last documented evaluation was 08/31/16. An annual evaluation was due on 08/31/17.
Patient # 11 was admitted on 05/20/17 and was an active patient at the time of the inspection. An annual evaluation was due on 05/20/18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists will receive a memo from Program Director regarding the timely completion of annual evaluations.
Clinical Supervisor and Lead Therapists will conduct random chart audits ensuring this paperwork is completed.
Clinical Supervisor will meet with therapists of open charts missing this documentation and documentation will be completed at this time. |
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.
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Observations
Based on a patient record review on May 21-22, 2018, the facility failed to document a treatment plan that outlines realistic short and long-term treatment goals as part of the comprehensive treatment plan in patient record # 22.
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Plan of Correction
Therapists will be reminded of comprehensive treatment plan regulations through memo.
During random chart audits, supervisors will ensure comprehensive treatment plans are completed and include short and long term treatment goals. |
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, #1,11, 15,19, and 22, the facility failed to document psychosocial evaluations in client records as of the date of the licensing inspection.
Client #1 was admitted on 02/03/18 and was still an active client at the time of the inspection. There was no psychosocial evaluation in the client record.
Client #11 was admitted on 5/20/17 and was still an active client at the time of the inspection. There was no psychosocial evaluation in the client record.
Client #15 was admitted on 09/20/17 and was discharged on 12/29/17. There was no psychosocial evaluation in the client record.
Client #19 was admitted on 04/04/18 and was discharged on 05/15/18. There was no psychosocial evaluation in the client record.
Client #22 was admitted on 12/11/17 and was discharged on 05/15/18. There was no psychosocial evaluation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists will be reminded of the DDAP required documentation through a memo from the Program Director.
Additionally, therapists will utilize supervision to explore barriers to engaging individuals in treatment sessions when this is presented as a barrier to completing paperwork.
Clinical Supervisor will conduct random chart audits to ensure that psychosocial evaluations are in the files and completed. |
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.
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Observations
Based on a review of 22 client records, the facility failed to document treatment plan updates within the regulatory timeframe in 5 client records reviewed.
Client #3 was admitted on 09/17/13 and was still an active client at the time of the inspection. A treatment plan update was completed on 10/17/17 and the next update was due no later than 12/17/17; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on 06/03/17 and was still active at the time of the inspection. A treatment plan update was completed on 10/20/17 and the next update was due no later than 12/20/17. A treatment plan update was completed on 2/22/18 and the next update was due no later than 4/22/18; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on 08/14/16 and was still active at the time of the inspection. Treatment plan updates completed on 07/19/17, 09/27/17, and 05/22/19 are all documented after the 60 day requirement.
Client # 8 was admitted on 08/05/16 and was still active at the time of the inspection. Treatment plan updates were not documented until 02/24/17 and client records were not updated every 60 days. The next treatment plan update was documented on 05/11/18.
Client #9 was admitted on 03/18/17 and was still active at the time of the inspection. A treatment plan update was completed on 02/14/18 and the next update was due no later than 04/14/18; however, the next update occurred on 04/28/18.
Client #11 was admitted on 05/20/17 and was still active at the time of the inspection. A treatment plan update was completed on 12/21/17 and the next update was due no later than 02/21/18; however, the next update occurred on 03/01/18. The next treatment plan update was due no later than 05/01/18, and there was no update documented in the record at the time of the inspection.
Client #20 was admitted on 01/30/18 and was still active at the time of the inspection. A treatment plan update was not documented in the client records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Therapists will be reminded of the regulation through a memo.
Supervisors will conduct random chart audits to ensure that all treatment plans are completed within the regulatory timeframe. When this is not possible due to non-compliance, the non-compliance will be documented and therapists will complete the documentation as soon as possible with the individual. |
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 ensure that the client was offered a copy of the consent to release information form and/or that the disclosures of client identifying information adhered to the limits established by 4 Pa. Code 255.5 (b) for releases of information where applicable in client record #'s 5, 7,11, 13,18, and 22. Additionally, some client records had consent to release information forms that lacked required information or were no longer valid.
Client #5 was admitted on 05/05/16 and was discharged on 04/27/18. The client record contained a consent to release information form to another treatment provider dated 04/11/18. There was no documentation that the client was offered a copy of the consent form. .
Client #7 was admitted on 08/14/16 and was still an active client at the time of the inspection. The client record contained a consent to release information form to a laboratory dated 02/28/18 along with other consent to release information forms dated 05/09/18. There was no documentation that the client was offered a copy of the consent forms.
Client #11 was admitted on 05/20/17 and was still an active client at the time of the inspection. The client record contained five consent to release information forms dated 05/22/17 to a laboratory, transportation company, government agency and funding sources that had expiration dates of 05/17/17. The consent to release information form for the emergency contact had expired, it was signed on 05/17/17, but, had not been updated.
Client #13 was admitted on 09/20/15 and was discharged on 12/12/17. The client record contained a consent to release information form dated 08/11/17, signed by the client and witness, that did not have the agency or person listed and was signed by the client and witnessed.
Client # 18 was admitted on 02/14/17 and was discharged on 10/09/17. The client record contained a consent to release information form dated 05/12/17 to a law enforcement agency.
Client #22 was admitted on 12/11/17 and was discharged on 05/15/18. The client record contained a consent to release information form dated 02/16/18 to another provider. did not acknowledge the client was offered a copy. There was no documentation that the client was offered a copy of the consent forms.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff that were found to have incomplete consent forms in charts will attend mandatory training on all components of the consent form. The training will be done by Program Director.
Supervisors will utilize supervision to answer questions about consent forms and Clinical Supervisor will conduct random chart audits to ensure that consent forms are being completed fully and properly.
Therapists will be responsible for reviewing all charts and active consent forms. Any consent form found to be incomplete will be updated with the client when possible and if not possible a new consent form will be generated. Supervisors will utilize chart audits to ensure current consent forms are completed correctly. |