INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a clinical supervisor on January 27, 2020 and was due to have the communicable disease trainings no later than January 27, 2021 There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Office Manager will track all required and completed trainings for all employees. Office Manager will work with Administrative Assistant to ensure that all employees have completed the required trainings within the regulatory timeframe. OM and AA will work to schedule on-site trainings when necessary to ensure all staff are in compliance with this regulation. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility 's fire drill logs for the year of 2020, the facility failed to conduct an unannounced monthly fire drill from the months of March 2020 until February 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Due to COVID 19 and to ensure social distancing, fire drills were not conducted to limit exposure. We will be filing for an exception as it would put women, children, and staff at an increased risk to conduct fire drills.
Office Manager will continue to monthly tracking of fire drills through logs and a spread sheet. Business Manager will randomly audit these logs to ensure that all fire drills are being completed monthly to comply with regulations. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of seven patient records, the facility failed to ensure that two patients reviewed received monthly drug screen.
Patient # 1 was admitted on July 15, 2020 and was still active at the time of the inspection. The patient record failed to include a drug screen for the month of November 2020.
Patient #4 was admitted on July 9, 2020 and was still active at the time of the inspection. The patient record failed to include a drug screen for the month of January 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Nursing will continue to track administration of monthly drug screening. Prior to the last week of the month, the nurse coordinator or designee will review any outstanding drug screens and schedule them for completion prior to the end of the month. If necessary, individuals will be called back to the program to complete drug screen if they are not due to return prior to the end of the month. |
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 seven patient records, the facility failed to 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.
Patient record # 4 was admitted on July 9, 2020 and was still active at the time of inspection. The facility only documented 30 minutes of psychotherapy for November 2020 and 1.15 hours of psychotherapy for December 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Supervisor reviewed regulations with counselors during group supervision.
Clinical Supervisor will address psychotherpay hours in individual session with counselors who are out of compliance. Clinical supervisor and Lead Counselor will randomly complete chart audits to ensure pscyhotherapy hours are in compliance.
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of seven patient records the facility failed to ensure that all applicable patient records received an aftercare plan.
Patient record #5 was admitted on November 18, 2018 and was discharged on August 6, 2020. The patient record failed to include an aftercare plan.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Supervisor spoke with counselor for patient record #5 regarding the missing Aftercare plan. Clinical Supervisor reviewed regulation. Clinical Supervisor and counselor created a check-list to ensure all documentation is completed within the timeframe. Clinical Supervisor will review and audit all closed charts. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of seven patient records the facility failed to ensure that all applicable patient records received a follow up.
Patient record #7 was admitted on October 26, 2017 and was discharged on March 20, 2020. The patient record failed to include follow up documentation.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The completion of this document was moved from the administrative assistant to the patient navigation team. Patient navigators complete the follow up documentation within the required timeframe. Patient Navigators were introduced to this new document, trained on completion and able to ask any questions during group supervision. |
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 seven client records, the facility failed to ensure that all treatment plans were updated every 60 days in five of the seven records.
Client record #1 was admitted on July 15, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 11, 2020 and an update was due no later than February 11, 2021, however at the time of the inspection no update was completed.
Client record #2 was admitted November 10, 2020 and was still active at the time of the inspection. A Treatment plan update was completed December 12, 2020 and an update was due no later than February 12, 2021, however at the time of the inspection no update was completed.
Client #3 was admitted on September 10, 2007 and was still active at the time of the inspection. A treatment plan update was completed on June 24, 2020 and an update was due no later than August 24, 2020, however an update was not completed until September 16, 2020.
Client #4 was admitted on July 9, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 4, 2020 and an update was due no later than February 4, 2021, however at the time of the inspection, no update was completed.
Client #7 was admitted on October 26, 2017 and was discharged on March 20, 2020. A treatment plan update was completed October 3, 2019 and an update was due no later than December 3, 2019, however an update was not complete by the time of discharge.
These findings were discussed with facility staff at the time of the inspection.
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Plan of Correction
Clinical Supervisor reviewed with counselors in group supervision the regulatory requirements of treatment plan updates being completed every 60 days. Clinical Supervisor reviewed with each therapist their tracking system to ensure this regulation was being met. Clinical Supervisor and Lead Counselor will review with counselors individually as needed. Clinical Supervisor and Lead Counselor will randomly complete chart audits to ensure treatment plans are being completed every 60 days. |