INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on December 6, 2021 through December 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.11(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 the facility-submitted Staffing Requirements Facility Summary Report and personnel records, the facility failed to document a written individual training plan for each employee that is to be developed annually with input from both the employee and the supervisor in one of twelve personnel records reviewed.Employee #1 was hired as the project director on September 1, 2019. There was no individual training plan documented in the record for the facility's current training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On January 3, 2022, approval was granted identifying the facility director as the project director. The facility director/project director will ensure that training plans for all personnel are completed in accordance with licensing standards. |
715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on direct observation of methadone dosing administration on December 7, 2021 at approximately 10:15 A.M., the facility failed to have sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area. The dosing wait-time for one patient was monitored by the Licensing Specialist upon the patient's arrival to the dosing area. The patient had still not received their medication dose prior to the Licensing Specialist's departure from that area, which was thirty-three minutes later.The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The observed wait time was a result of a recent nursing resignation. Recruitment was underway at the time of the inspection and a new medicating nurse was hired effective 12/22/21. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on direct observation of methadone dosing administration on December 7, 2021 at approximately 10:00 A.M., the facility failed to ensure that only authorized staff and patients who are receiving medication shall be permitted in the dispensing area and to ensure there shall be only one patient permitted at the dispensing station at any given time. While dosing of patients was occurring at the middle dosing window, there was another patient seated in direct view of other patients receiving their medication. Also, at the same time of dosing, there was a patient who was being administered an oral drug screening with direct visibility of the dosing window. The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The need to provide patient privacy and confidentiality during the medication dispensing process has been reviewed with nursing personnel. They have been instructed to ensure that no unauthorized individuals will be present in the dispensing area. As such, only one person will be permitted in the medicating area per nurse. This should ensure compliance with the standard. The Nursing Supervisor will periodically review the environment of care for deficiencies and engage nurse in education when deemed necessary. |
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, the facility failed to ensure that each patient received at least 2.5 hours of psychotherapy group and individual sessions per month during the patient's first year in treatment in one of four applicable patient records reviewed.Patient #3 was admitted on May 28, 2021 and was active at the time of inspection. The record documented the following psychotherapy hours provided to the patient: 60 minutes during November 2021, 60 minutes during October 2021, 60 minutes during September 2021, 0 hours during August 2021 and 0 hours during July 2021.This is a repeat citation from the February 17, 2021 annual licensing renewal inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Clinical Operations Manager to ensure compliance with this standard. This will be accomplished via monthly chart review conducted by Clinical Supervisors, the findings of which will be reported to the Clinical Operations Manager. In instances when a deficiency in contact is noted, the COM and Clinical Supervisor will meet with the therapist to develop a plan of emgagement. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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, the facility failed to ensure that each patient, in treatment for 4 or more years, received at least 1 hour of psychotherapy group or individual sessions every two months in one of three applicable patient records reviewed.Patient #1 was admitted on February 21, 2008 and was active at the time of inspection. The record documented the following psychotherapy hours provided to the patient: 0 hours during August 2021 and 0 hours during July 2021.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Clinical Operations Manager to ensure compliance with this standard. This will be accomplished via monthly chart review conducted by Clinical Supervisors, the findings of which will be reported to the Clinical Operations Manager. In instances when a deficiency in contact is noted, the COM and Clinical Supervisor will meet with the therapist to develop a plan of contact. |
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 obtain an informed and voluntary consent to the funding source in one of seven client records reviewed. Client #5 was admitted on October 17, 2016 and was discharged October 25, 2021. There was an informed and voluntary consent signed and dated by the client on October 16, 2020 that expired on October 15, 2021. However, the facility failed to have the client complete a new voluntary consent to the funding source and there was documentation of billing to the funding source after the expiration of the consent. The findings were discussed with facility staff during the licensing process
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Plan of Correction
It shall be the responsibility of the Clinical Operations Manager to educate the therapeutic staff on the need for timeliness of all consent and release of information materials, especially in those instances when client completion of treatment is imminent. It will be the responsibility of the Program Coordinator to ensure at the time of discharge that staff are meeting the standard. In cases where deficiencies are noted, therapists will receive ongoing training on appropriate discharge procedures. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on informed and voluntary consent forms in one of seven client records reviewed.Client #1 was admitted on February 21, 2008 and was active at the time of inspection. A release of information form was signed and dated by the client on January 24, 2021; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To ensure compliance with this standard, the Release of Information Form associated with Annual Review has been modified to highlight the required fields. It shall be th responsibility of the Clinical Supervisors, to ensure via monthly chart review, that ROIs are being completed in compliance with the standard. |
711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
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:
(iv) The dated signature of the client or guardian.
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Observations
Based on a of client records, the facility failed to obtain a dated signature of the client on informed and voluntary consent to release information forms in four of seven client records reviewed.Client #1 was admitted on February 21, 2008 and was active at the time of inspection. There were consent to release information forms, in the record, to a funding source and a government agency that were not signed and dated by the client.Client #2 was admitted on June 16, 2020 and was active at the time of inspection. There were consent to release information forms, in the record, to a funding source and an emergency contact that were not signed and dated by the client.Client #4 was admitted on November 12, 2004 and was discharged September 9, 2021. There were consent to release information forms, in the record, to a funding source, a government agency, a laboratory, a transportation service, and an emergency contact that were not signed and dated by the client.Client #5 was admitted on October 17, 2016 and was discharged October 25, 2021. There were consent to release information forms, in the record, to a funding source, a government agency, a laboratory, a transportation service, and an emergency contact that were not signed and dated by the client.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to the ongoing public health crisis, therapeutic staff were instructed to forego in-person sessions for the purpose of social distancing. As such, many ROI forms lacked patient signatures but were verbally acknowledged. In response to the inspection, therapists have been informed that all ROI forms and consents must bear client signature. Monthly review of charts will ensure compliance with the standard. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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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 all informed and voluntary consent to release information forms in two of seven client records reviewed.Client #1 was admitted on February 21, 2008 and was active at the time of inspection. A release of information form was signed and dated by the client on January 24, 2021; however, there was no documentation that a copy of the form was offered to the client. Client #6 was admitted on March 24, 2014 and was discharged April 17, 2021. A release of information form was signed and dated by the client on March 24, 2020; however, there was no documentation that a copy of the form was offered to the client. The findings were discussed with facility staff during the licensing process
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Plan of Correction
It shall be the responsibility of the Clinical Operations Manager to educate the therapeutic staff on the need to both offer and document that a copy of all consents and releases have been offered at the time of signing. Monthly chart review findings conducted by the Clinical Supervisory Personnel, and reported to the Clinical Operations Manager, will ensure compliance with the standard. |