INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on December 1, 2021 through December 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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;
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Plan of Correction
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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 provide each patient with at least 2.5 hours of psychotherapy, 1 hour of which shall be individual psychotherapy, per month during the patient's first year in treatment in one of five applicable patient records reviewed.Patient #1 was admitted on April 30, 2021 and was active at the time of inspection. The record of service and progress notes indicated that the following psychotherapy hours were provided to the patient: 30 minutes for November 2021, 15 minutes for October 2021, 15 minutes for September 2021, and 1.75 hours for August 2021.This is a repeat citation from the February 24, 2021 annual licensing renewal inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor reviewed regulations with counselors during group supervision on 12/13/21.
Clinical Supervisor will address psychotherapy hours in individual sessions with counselors who are out of compliance and support them in implementing appropriate interventions.
Clinical Supervisor will randomly complete chart audits to ensure psychotherapy hours are in compliance.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to document the results of all annual physical examinations given by the narcotic treatment program, which includes an annual reevaluation by the narcotic treatment physician, in three of five applicable patient records reviewed.Patient #2 was admitted on June 23, 200 and was active at the time of inspection. The last documented physical exam was the initial exam completed on September 11, 2020.Patient #4 was admitted on March 15, 2018 and was discharged June 1, 2021. The last documented physical exam was the initial exam completed on March 4, 2020.Patient #5 was admitted on March 21, 2005 and was discharged September 17, 2021. The last documented physical exam was the initial exam completed on May 31. 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual physicals will be bundled with the annual psychiatric evaluation to help ensure they are completed.
The new electronic health record system has been organized to ease tracking of annual physical needs
The Nurse Coordinator will audit the list of physical needs monthly and schedule as appropriate.
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715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on a review of patient records, the facility failed to document, in the record, counselor notes regarding the patient ' s progress and status in one of five applicable patient records reviewed.Patient #1 was admitted on April 30, 2021 and was active at the time of inspection. There was no patient progress notes documented in the record as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The counselor for patient record #1 is no longer an employee of Jefferson Family Center. Clinical Supervisor has included a memo clarifying the clinical documentation issue in all charts for this counselor.
Clinical Supervisor reviewed documentation regulations with counselors during group supervision.
Clinical Supervisor will regularly review report on billed and signed notes in ECR.
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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 a complete client record, which is to include follow-up information, in two of two applicable records reviewed.Client #5 was admitted on March 21, 2005 and was discharged September 17, 2021. Client # 7 was admitted July 12, 2016 and was discharged March 31, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The completion of this document was moved from the Patient Registrar to the Peer Specialist. CPS was trained on the completion of and timeline for this document, and is able to ask questions and problem solve during individual supervision. |
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 review of client records, the facility failed to obtain a dated signature of the client on consent to release information forms in one of seven client records reviewed.Client #5 was admitted on March 21, 2005 and was discharged September 17, 2021. There were witness-signed consent to release information forms to a funding source, a government agency, a laboratory and an emergency contact documented in the record; however, none of the consent forms contained a dated signature of the client.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviewed all requirements for signing consents with clinical team in team meeting 12/7/21.
The ECR will ensure all required information is completed in order for the document to be signed and completed.
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