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 20, 2024 through November 21, 2024 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(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, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of four applicable personnel records reviewed.
Employee # 6 was hired as a counselor on April 9, 2023 and was due to have the TB/STD training no later than April 9, 2024. There was documentation in the personnel record indicating that the TB/STD training was completed late on October 28, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was received on 11/21/2024 for a clinician who did not complete the required TB/STD training hours within their first year of employment. In response, the Thomas Jefferson University NARP program has implemented a monitoring schedule to ensure full compliance with DDAP-required staff training as of August 2023. This process aims to ensure that new employees complete their training within the required timelines and that all staff have access to ongoing clinical and professional development opportunities.
Clinical Supervisors are closely monitoring the compliance of incoming staff with DDAP training requirements and ensuring that they are provided with the most up-to-date training dates from the DDAP websites. Clinical Supervisors will monitor staff charts for monthly compliance within the first year of employment. This process will ensure that staff meet all training requirements in a timely manner and that any deficiencies are addressed promptly. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's January 2024 through October 2024 fire drill logs, the facility failed to ensure their written fire drill logs documented whether the fire alarm or smoke detector was operative during a fire drill.
Each fire drill log reviewed was missing documentation of whether the fire alarm or a smoke detector was operative during the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Citations were received on [DATE] regarding the lack of written documentation on the operational status of both fire alarms and smoke detectors during fire drills. In response, a plan of correction was developed on 12/19/2024 by the TJU NARP Executive Director to address this deficiency and prevent recurrence. In order to correct this action, the fire alarms and smoke detectors were tested on 12/16/2024 and were all in working order. To prevent this from happening in the future, The Executive Director will establish a monthly fire alarm and smoke detector testing protocol to ensure all alarms are operational and functioning properly. The Practice Manager will be responsible for overseeing and maintaining these logs to document the completion of the monthly checks of the functioning of the fire and smoke alarms in compliance with DDAP regulations. This corrective action will be implemented by 1/31/2025. |
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 facility's January 2024 through October 2024 fire drill logs, the facility failed to ensure the fire alarm, or a smoke detector was set off during each fire drill.
Each fire drill log reviewed was missing documentation that the fire alarm or a smoke detector was set off during each drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Citations were received on [DATE] regarding the lack of written documentation on the operational status of both fire alarms and smoke detectors during fire drills. In response, a plan of correction was developed on 12/19/2024 by the TJU NARP Executive Director to address this deficiency and prevent recurrence. In order to correct this action, the fire drill log for December 2024 will reflect whether the fire or smoke alarm were set off during the drill. This will be done by 12/31/2024. In addition, to prevent this from happening in the future, The Executive Director updated the current fire drill log to include a section to note whether the fire and smoke alarms were set off during the drill. This was completed on 12/19/2024. The Practice Manager will be responsible for overseeing and maintaining these logs to document the the monthly fire drills with notation of whether the fire and smoke alarms were set off each drill in compliance with DDAP regulations. This corrective action will be implemented by 1/31/2025. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure the narcotic treatment physician reviewed the dosage levels to determine a patient ' s therapeutic dosage at least twice a year in one of four applicable patient records reviewed.
Patient #3 was admitted on February 6, 2012 and was active at the time of inspection. There was no documentation of any dosage level reviews completed during 2024 in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was received on 11/21/2024 for failure to document dose level reviews every 6 months. In response, a plan of correction was developed on 12/19/2024 by the TJU NARP Executive and Medical Directors to address this deficiency and prevent future occurrences. The active client records are being reviewed beginning 12/19/2024 through 1/21/2025 so that all Medication Orders will be renewed and methadone or buprenorphine doses are reviewed by the medical team. These reviews will be documented in the EHR Medication Order by the medical and nursing staff. To prevent this citation from occurring in the future, the Executive
Director will implement a required task checkbox to confirm that the medical team has reviewed a patient's dose during the annual psychiatric evaluation. Additionally, a comment will be added to the medication order to document the review of the patient's dose when it is refilled every 6 months, coinciding with the expiration of the medication order. This update will be implemented by 1/31/2025, and the lead nurse will be responsible for reviewing documentation to ensure ongoing compliance. |
711.92(c)(2) LICENSURE Type & Frequency of TX
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the client's comprehensive treatment plan in one of three applicable client records reviewed.
Client # 2 was admitted on August 27, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan, completed on September 26, 2024, did not include written documentation of the type and frequency of services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was received on 11/21/2024 for treatment plans not including the type of treatment and the frequency of treatment. In response, the Thomas Jefferson University NARP program has developed a plan of correction to address this deficiency and prevent its recurrence. On 12/19/2024, the TJU NARP Executive Director and Clinical Supervisor implemented a corrective plan. Counselors will make an addendum to patient treatment plans to specify the type of intervention (e.g., individual and/or group psychotherapy) and the frequency of those interventions. This will be completed by 12/22/2024, and NARP Clinical Supervisors will review the updated treatment plans by 12/23/2024 to ensure compliance.
To prevent this citation from occurring in the future, the Executive Director made adjustments to the electronic health record (EHR) system on 12/19/2024. These adjustments include a designated area in the EHR for counselors to indicate the type of treatment and the frequency of treatment. This update ensures that treatment plans created or updated after 12/19/2024 will prompt counselors to enter the necessary information.
Furthermore, the NARP Clinical Supervisors will conduct a training session for counselors on how to properly complete treatment plans in the EHR, with a specific focus on documenting the type and frequency of treatment. The training is scheduled to be completed by 1/31/2025. Compliance will be monitored through weekly chart audits conducted by the Clinical Supervisors, with the Executive Director overseeing the process through additional audits and supervision meetings with the Clinical Supervisors. These actions are aimed at ensuring ongoing compliance with treatment planning requirements. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to include the purpose of disclosure on consent to release information forms in three of seven client records reviewed.
Client # 1 was admitted on February 22, 2024 and was active at the time of inspection. The consent to release information form to a family member/friend, signed by the client on April 18, 2024, did not include the purpose of disclosure. Additionally, the consent to release information form to another treatment provider, signed by the client on February 27, 2024, did not include the purpose of disclosure.
Client # 2 was admitted on August 27, 2024 and was active at the time of inspection. The consent to release information forms to a family member/friend and another treatment provider were signed by the client on August 27, 2024, but neither release form included the purpose of disclosure.
Client # 6 was admitted on March 22, 2024 and was discharged on September 13, 2024. The consent to release form to a family member/friend, signed by the client on March 25, 2024, did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Thomas Jefferson University NARP program transitioned from paper charts to an electronic health record (EHR) system in July 2024. A citation was received for missing the type of information to be disclosed to multiple entities on a release of information form. In response, a plan of correction was developed on 12/19/2024 by the TJU NARP Executive Director and Clinical Supervisors to address this deficiency and prevent future occurrences.
As part of the corrective action, counselors will complete new releases of information for active clients that include the type of disclosures to be made to the multiple entities. This will be completed by 1/31/2025, and Clinical Supervisors will review all multiple entity releases of information to ensure they are fully completed with the necessary disclosure information by 1/31/2025.
To prevent this citation from recurring, the Executive Director made adjustments to the EHR on 12/19/2024 to ensure that all releases of information for multiple entities now include a required field specifying the type of information that will be disclosed to each entity, in compliance with regulations.
Compliance will be monitored through weekly chart audits conducted by the Clinical Supervisor. The Executive Director will oversee compliance through additional chart audits and supervision meetings with the Clinical Supervisor. |
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 document that a copy of a client consent was offered to the client in one of seven client records reviewed.
Client # 1 was admitted on February 22, 2024 and was active at the time of the inspection. The consent to release information form to a family member/friend was signed by the client on April 18, 2024; however, there was no documentation indicating a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Thomas Jefferson University NARP program transitioned from paper charts to an electronic health record (EHR) system in July 2024. A citation was received for a consent form that did not include whether a copy was offered to the client. In response, a plan of correction was developed on 12/19/2024 by the TJU NARP Executive Director and Clinical Supervisors to address this deficiency and prevent it from occurring in the future.
As part of the corrective action, counselors will complete an addendum to the release of information for active clients who had missing information regarding whether a copy was accepted by the client. This will be completed by 1/31/2025, and Clinical Supervisors will review all release of information forms to ensure they are fully completed, including whether the patient accepted a copy of the form.
To prevent future occurrences, the Executive Director implemented a change in the EHR system on 12/19/2024. All Releases of Information and Consent forms now include a required field confirming whether a copy was accepted by the client. The EHR will prompt staff to complete
all necessary sections before a form can be finalized, with a notification for any incomplete fields.
Compliance will be monitored through weekly chart audits by the Clinical Supervisor, with additional oversight by the Executive Director through further chart audits and supervision meetings. Additionally, the Clinical Supervisor will provide training to counselors on the importance of completing all required fields on Releases of Information in order to comply with state regulations and utilize the new EHR system effectively to prevent omissions in the future. This training will be completed by 1/31/2025. |