INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 18-20, 2014 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position of counselor in one out of three personnel records reviewed.
The findings include:
Three personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that employee #4 met the experiential qualifications for the position of counselor.
Employee # 4 was hired as a counselor on September 16, 2014. Employee # 4 has a Bachelor's Degree with a qualifying major. However, employee # 4 only had five months of the required clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Program Coordinator to ensure that all new clinical employees have the relevant education and experience for the position for which they have been hired. Specifically counselors will be expected to hold a Master's degree in a relevant field. With respect to Employee 4, she is demoted to Counselor Asst until her credentials warrant promotion to counselor status. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on an observation on November 19, 2014, the facility failed to ventilate bathrooms by an exhaust fan or window in two of two client bathrooms.
The findings include:
A physical plant inspection was conducted on November 19, 2014 from approximately 8:15 A.M. to 9:30 A.M. It was observed during the inspection that the two bathrooms on the first floor were not ventilated by an exhaust fan or window.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Program Coordinator to ensure that the clinical environment meets standards. To achieve this, the Program Coordinator and/or her designee will conduct monthly walk throughs of the environment of care, including the restrooms, to ensure that the physical plant is in compliance. The Program Coordinator has ensured that exhaust fans were installed in the two bathrooms on the first floor and conducts monthly checks to ensure that they are still in working order. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on observations on November 19, 2014, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on November 19, 2014. It was observed during the inspection from approximately 8:15 A.M. to 9:30 A.M., that the following fire extinguishers in the facility had not been inspected and approved by the local fire department or fire extinguisher company since June 2013:
1)Fire extinguisher on the first floor near the dispensing area.
2)Fire extinguisher on the first floor in the hallway near the client bathrooms.
3)Fire extinguisher on the first floor near the staff bathrooms.
4)Fire extinguisher on the second floor in the lobby.
5)Fire extinguisher on the second floor in the lounge area.
6)Fire extinguisher on the second floor near the rear door.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Facility Director to ensure that all contracts, including one with the firm that services fire extinguishers in the facility, are executed in a timely fashion. The Facility Director has ensured that the following fire extinguishers have been inspected and approved by the fire extinguisher company:
1) Fire extinguisher on the first floor near the dispensing area.
2) Fire extinguisher on the first floor in the hallway near the client bathrooms.
3)Fire extinguisher on the first floor near the staff bathrooms.
4)Fire extinguisher on the second floor in the lobby.
5)Fire extinguisher on the second floor in the lounge area.
6)Fire extinguisher on the second floor near the staff bathrooms.
It is the responsibility of the Facility Director to ensure that all of the fire extinguishers in the facility are inspected and approved annually by the fire extinguisher company.
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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 client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in six of twelve records reviewed.
The findings include:
Twelve client records requiring documentation of a treatment plan update were reviewed from November 18, 2014 to November 20, 2014. The facility failed to document a treatment plan update at least every 60 days in client records # 1 3, 4, 10, 16, and 18.
Client # 1 was admitted June 5, 2014 and was still an active client as of 11/20/14. A treatment plan update was completed August 25, 2014 and the next treatment plan update was due October 24, 2014. However, client record # 1 did not include documentation of an additional treatment plan update as of November 20, 2014.
Client # 3 was admitted March 18, 2014 and was still an active client as of 11/20/14. A treatment plan update was completed August 26, 2014 and the next treatment plan update was due October 25, 2014. However, client record # 3 did not include documentation of an additional treatment plan update as of November 20, 2014.
Client # 4 was admitted April 14, 2014 and was still an active client as of 11/20/14. A treatment plan update was completed July 24, 2014 and the next treatment plan update was due September 22, 2014. However, the next treatment plan update was not completed until September 30, 2014.
Client # 10 was admitted October 5, 2012 and was discharged August 19, 2014. A treatment plan update was completed March 31, 2014 and the next treatment plan update was due May 30, 2014. However, the next treatment plan update was not completed until June 11, 2014.
Client # 16 was admitted January 17, 2012 and was still an active client as of 11/20/14. A treatment plan update was completed July 28, 2014 and the next treatment plan update was due September 26, 2014. However, the next treatment plan update was not completed until October 14, 2014.
Client # 18 was admitted October 9, 2009 and was discharged May 6, 2014. A treatment plan update was completed January 28, 2014 and the next treatment plan update was due March 29, 2014. However, client record # 18 did not include documentation of an additional treatment plan update as of November 20, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the Clinical Supervisors to ensure that treatment plan updates (i.e. Comprehensive and 60 Day Updates) are completed within the prescribed time frame. The Clinical Supervisors will educate counseling staff on both the importance of, and ways to achieve timely treatment plan completion. Supervisory personnel will, for a period of 3 months, select a random sample of records and review them for timeliness of treatment plan completion.
The past due treatment plan update is now completed for Client #1, Client #4, and Client #16. The facility will discharge Client #3. |