INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 31, 2008 through February 1, 2008 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 and a plan of correction is due on February 28, 2008.
|
Plan of Correction
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Based on a review of personnel records and facility data, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants. Data presented by the facility demonstrated a 15 full time equivalency for counselors and counselor assistants and no full-time clinical supervisor.
|
Plan of Correction
The request for exception filed by this facility has been rejected by the Division of Drug and Alcohol Program Licensure. Our program will now move forward with appointing a doctoral-level, senior member of administration as the Facility Director.
The Program Coordinator for NARP and the Senior Therapist for IOP will both be full-time clinical supervisors with minimal caseloads. The Division Director, Coordinator of Treatment, and Senior Therapist are available for assistance with any additional supervisory needs.
Staff Responsible: Division Director.
|
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
Based on a review of facility policy and procedure, the facility failed to include time frames for the completion of an overall plan to address staff training needs and an annual evaluation of the overall training plan.
|
Plan of Correction
Working with the Division Director, the Coordinator of Treatment and Training will modify the Policy and Procedure manual so that it includes timeframes for 1) the development of the Division's overall plan for addressing staff training needs and 2) when the plan will be reviewed.
Staff Responsible: Division Director, Associate Division Director, Coordinator of Treatment & Training
|
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.
|
Observations
Based on a review of client records, the facility failed to document goals stated in terms of measurable criteria in six of ten client records reviewed, #2, 3, 5, 6, 9 and 10.
|
Plan of Correction
An administrative team, consisting of the Coordinator of Training and Treatment, the Program Coordinator (NARP), and senior clinicians (NARP and IOP), has begun designing a series of interactive trainings that will help staff to develop greater skill in treatment plan development and other documentation. These group training sessions will be followed up by individual supervisory meetings that will focus on examining/modifying treatment plans to criterion.
Staff Responsible: Coordinator of Treatment & Training |
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.
|
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 ten of ten client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
|
Plan of Correction
First, upon examining the paperwork used in treatment planning, it was determined that insufficient space was allotted for the documentation of progress updates on goals. In response, the available space has been enlarged to allow clinical staff to provide a more thorough assessment of client progress.
Secondly, as mentioned in the last response [711.92 (c)(1) above], administrative personnel is currently designing a series of intensive trainings related to appropriate documentation. Staff will be trained to create more attainable, measurable goals on their treatment plans, which should then make documentation of progress easier. Training will emphasize the need to refer back to goals and actions steps, assess what progress has been made, and then a clinical assessment of what might be impeding progress or what changes can be made to intervention.
Responsible Staff: Program Coordinator and Senior Therapist (NARP), Senior Therapist (IOP) |
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.
|
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 10/19/07 to 11/20/07 and from 11/30/07 to 12/26/07 in client record #1. Individual sessions were not documented from 12/05/07 to 01/02/08 in client record #2. Individual sessions were not documented from 10/12/07 to 11/13/07 in client record #3. Individual sessions were not documented from 12/12/07 to 01/16/08 in client record #4. All of these clients were scheduled for weekly individual sessions.
|
Plan of Correction
First, staff will be reminded that in addition to therapy sessions they have each week, they are expected to document when and why planned sessions do not occur. If a treatment plan states that the client and clinician will meet weekly, then documentation should be present each week. They will be expected to provide brief explanations for missed sessions, and there is the expectation that the clinician will attempt to contact clients (and document this) if they do not attend scheduled sessions.
Secondly, each clinician will be required to indicate on their monthly caseload report, (which includes client admission dates) therapy session dates for the month, and length of sessions. The Program Coordinator and Senior Therapist will, during treatment plan review meetings, monitor session frequencies for each therapist and compare this to treatment plan goals. When sessions occur less frequently than specified in the treatment plans, this will be addressed by the Program Coordinator and Senior Therapist. When needed, additional training may be provided on how to more effectively engage clients who are non-compliant.
Staff Responsible: Program Coordinator (NARP), Associate Division Director (IOP)
|
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in three of six client records reviewed, #14, 15 and 16.
|
Plan of Correction
The support staff of each program will, on a monthly basis, provide a list of individuals who are due for 60-day follow-up contact to clinical staff as well as to their supervisors. It is the responsibility of each clinician to attempt to contact their former clients and document this contact. Supervisory staff will then verify that this paperwork has been filed in the client's record.
Staff Responsible: Program Coordinator (NARP), Senior Clinicians (NARP and IOP)
|