INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2008 through January 29, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on February 28, 2008.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record, the facility failed to document that staff and clients exited the building during fire drills in 2007.
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Plan of Correction
This issue has been corrected all monthly scheduled drills will include documentation that staff and clients exited from each floor. A staff training will be scheduled to inform staff of citation and full plan to exit the building on a monthly basis to meet the standard.
Person Responsible: Program Director and Floor Captains
Timeframe of completion: March 1, 2008 |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the administrative records, the facility failed to provide documentation that the fire alarm or smoke detector was in working order as required per the letter of exception, dated March 10, 2005, that approved an alternate procedure for conducting fire drills.
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Plan of Correction
Unfortunately, we had no control in obtaining the fire inspection documents completed on the entire building in December, 2007, despite daily phone calls to the building manager to send them to us. An individual inspection occurred on 2/13/08 with the security/alarm contractor testing each alarm by setting off both fire and smoke detectors. The yearly inspection of the fire alarma dns moke detection systems will be obtained, upon their completion, from the 1233 Management Company. The importance of this issue has been discussed with the builing manager and reinforced in writing.
Person responsible: Program Director
Timeframe for completion: 2/13/08 |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document goals stated in terms of measurable criteria in three of six client records reviewed, #3, 4 and 6.
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Plan of Correction
Staff have received a training that specifically addressed how to identify goals, how to write goals, and how to state measurability. This training and on-going weekly clinical supervision should address this deficiency. Treatment plans will be monitored, when presented, for compliance.
Person(s) responsible: Program Director and Clinical Consultant
Timeframe for completion: 2/13/08 |
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 an assessment of the client's progress in relationship to the stated goals of the treatment plans in five of seven client records reviewed, #1, 2, 3, 5 and 6.
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Plan of Correction
A training was held to address the correct clinical documentation indicating the clinical progress and/or barriers to the previous treatment plan. In particular, individuality of progress was emphasized. Addtionally, Treatment Plan Updates will be reviewed in weekly supervision.
Person(s) responsible: Program Director and Clinical Consultant
Timeframe for completion: 2/13/2008 |
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plans in four of six client records reviewed, #1, 2, 3 and 4. Individual sessions were not documented from 11/20/07 to 01/02/08 in client record #1. Individual sessions were not documented from 11/07/07 to 12/10/07 in client record #2. Individual sessions were not documented from 09/21/07 to 10/26/07 in client record #3. Individual sessions were not documented from 12/10/07 to 01/07/08 in client record #4. All of these clients were scheduled for weekly individual sessions.
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Plan of Correction
A training was held to address the importance of documenting and using "no show" progress notes; CIS forms that also indicate "no show"; placing clients on "hold" so that the issue of non-compliance to the minimal required hours can be met. CIS non-shows will be monitored in weekly supervision to insure progress notes, behavior contracts, etc. address this deficiency
Person(s) responsible: Program Director and Clinical Consultant
Timeframe for completion: 2/13/08
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711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in four of six client records reviewed, #8, 10, 11 and 12.
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Plan of Correction
A training was held to address this deficiency with all staff, particularly newer staff. The Administrative Clinic Coordinator and the Program Director have develop a reminder log to insure compliance.
This log will be kept in the Administrative Clinic Coordinators office and monitored on a monthly basis when the monthly statisitcs are completed and submitted to the Program Director.
Person(s) responsible: Program Director, Clinical Consultant, and Administrative Clinic Coordinator
Timeframe for completion: 2/13/08 |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a review of client records, the facility failed to obtain a court order for the release of client information as required by 42 CFR Part 2, Subpart E, The facility released information regarding the client's identity to police and another client when a client made threatening statements off grounds towards another client, record #8. The client did not make the commission of a crime on the premises of the program or against program personnel pursuant to 42 CFR Part 2, Subpart B, 2.12(c)(5)(i)&(ii).
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Plan of Correction
A training was held for all staff who have responsibility for completing any confidential patient releases and the proper procedure to obtain a court order to release same to the police. Also, discussed was the procedure if the crime, or threats of an intended crime, were initiated on the premises or against program personnel. Release will be reviewed upon admission and on a random basis by the Clinical Supervisor
Person(s) Responsible: Clinical Supervisor, Program Director, Clinical Consultant
Timeframe for completion: Immediate |