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 30 - December 1, 2015 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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704.11(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 the Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons 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. All other staff shall complete the training within the first 2 years of employment. The findings include:The Staffing Requirements Facility Summary Report form was reviewed on December 1, 2015. The facility failed to ensure all staff persons received a minimum of 6 hours HIV/AIDS training and at least 4 hours of TB/STD training, specifically employee # 11.Employee # 11, support staff was hired October 7, 2013. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by October 7, 2015. The facility failed to ensure employee # 11 completed HIV/AIDS and TB/STD training as of the time of inspection.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It shall be the responsibility of the Division of Substance Abuse Program's Treatment and Training Coordinator to ensure that support staff receive mandated trainings in a timely manner. Compliance will be ensured via annual review of training logs during yearly performance reviews. When potential deficiencies are noted, staff will be enrolled in appropriate trainings. Employee 11 will be scheduled at the earliest opportunity. Employee 11 is scheduled for Confidentiality on February 17. Basic HIV training is scheduled for April 18th and TB/STD on April 25. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds clean, safe, and sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The findings include:A physical plant inspection was conducted on December 1, 2015. The facility failed to keep the grounds in good repair at all times, specifically the stairs in the 2nd floor emergency exit corridor.A concrete step within the emergency exit corridor was cracked and damaged posing a tripping and safety hazard. In addition, this exit was not lit and the light fixture was hanging from the wall.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The stair has been repaired as of 12/17/15. The light fixture cited remains affixed to the ceiling and is lit. Routine review of the facility, including the emergency stairwell, to be conducted by maintenace personnel with a report issed to the Facility Manager, will ensure future compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that there were no heaters that were not permanently mounted or installed within the facility.The findings include:A physical plant inspection was conducted on December 1, 2015. A portable space heater that was not permanently mounted or installed was observed within an occupied office.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It shall be the responsibility of the Facility Director and Office Manager to ensure that no portable space heaters are used on site. Staff have been informed via weekly staff meeting. Routine walk throughs of the facility, to be conducted by the Office Manager, will ensure compliance with the standard. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility failed to ensure interior exits were lit at all times.The findings include:A physical plant inspection was conducted on December 1, 2015. The facility failed to ensure interior exits were lit at all times. The facility's second floor emergency exit was not lit at the time of the inspection. The light at the bottom of the exit was not lit and light fixture was hanging from the wall.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Long lasting LED bulbs have been installed by the Facility Manager to ensure that the fixture remains lit. Routine walk throughs of the physical plant, to be conducted by the Facility/Office Manager, will ensure compliance. The light fixture in question remains affixed to the ceiling and is not hanging from the wall. |
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 a physical plant inspection, the facility failed to ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.The findings include:A physical plant inspection was conducted on December 1, 2015. All of the fire extinguishers within the facility were expired and were last inspected November 30, 2014.1)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.The findings were reviewed with facility staff during the licensing inspection.This is a repeat deficiency. The facility was previously cited for non-compliance on November 20, 2014.
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Plan of Correction
It shall be the responsibility of the Facility Director or his designee, to ensure timely inspection of facility fire extinguishers. Random review of fire extinguishers by the Facility Director will ensure compliance with the requirement of annual revew. Fire extinguishers have been inspected/serviced by TYCO on 12/14/15. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon staff employment.The findings include:Eight personnel records were reviewed on December 1, 2015, to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to ensure employee # 9 completed fire extinguisher training upon employment.Employee # 9 was hired November 2, 2015. Fire extinguisher training was due upon hire; however employee # 9 did not complete the training until November 11, 2015 The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
While this POC only applies to a single episode (two days overdue), it shall be the responsibility of the Corodinator of Treatment and Training to ensure timely training of all new employees in the use of facility fire extinguishers. Upon employment all new staff will complete fire extinguisher training. Review of personnel records will ensure compliance with the standard. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of administrative documentation, the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.The findings include:Based on a review of the medical director's time sheets which were provided for the month of July 2015, August 2015, September 2015 and October 2015 the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week for every ten patients. The facility's census on November 30, 2015 and December 1, 2015 were 406 patients; therefore, the narcotic treatment program was required to provide at least 41 physician hours per week. Based on the provided and reviewed time sheets the physician provided less than 41 hours per week for the month of July 2015, August 2015, September 2015 and October 2015. The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
New medical personnel have been hired and will be beginning in February 2016. It shall be the responsibility of the Facility Director to secure additional on-site physician time from the remaining physicians as well as the TJU Department of Psychiatry should such shortages in coverage recur.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to document in the patient's record the basis for the determination of current dependency and evidence of a 1 year history of addition.The findings include:Nine patient records were reviewed on December 1, 2015. The narcotic treatment physician failed to document 1 year of opiate addiction and current opiate addiction in two out of nine patient records reviewed. Patient # 1 and 2 did not have documentation of current dependency and evidence of a 1 year history of addition presented within their records.The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Documentation of a current dependency and one year history on opioids is located in multiple locations within the clinical record. Copies of the documentation for patients #1 & 2 were forwarded to DDAP for review (as requested). During future inspections, the facility and its representatives (i.e., Program Coordinator, Clinical Supervisor) will ensure that the licensing specialist is aware of the location of the documentation (i.e., in the medical section of the clinical record) prior to the review of charts.
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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 physician failed to review or provide documentation of dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient's therapeutic dosage.The findings include:Six patient records were reviewed on December 1, 2015, for documentation of a semi-annual physician dose review. The narcotic treatment physician failed to provide documentation of dosage levels at least twice a year to determine a patient's therapeutic dose, specifically for patient #4.Patient #4 was admitted to the narcotic treatment program on April 5, 2013. Patient record #4 contained two dose reviews on June 16, 2014 and May 1, 2015.The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Medical personel have been reminded of the need for bi-annual dosage level reviews for all individuals enrolled in medication assited treatment. Compliance will be ensured via random audit of clinical records to be conducted by administrative personnel, including the Facility Director, Program Coordinator, Clinical Supervisors, and Coordinator of Treatment and Training. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document whether a patient may be provided take-home medications.The findings include:Three take-home patient records were reviewed on December 1, 2015, for documentation that the narcotic treatment physician determined a patient is responsible and able to handle narcotic drugs outside the narcotic treatment program. The narcotic treatment physician failed to document justification for take-homes or an exception for patient # 8 who is disabled. Patient # 8 was transferred-into the program from a long-term care facility on July 29, 2015 and given a 13 day take-home privilege; however, the facility failed to document the rationale for permitting the 13 day take-home. The narcotic treatment physician failed to document whether patient # 8 was responsible in handling narcotic drugs and maintain documentation of an exception in the patient's record. The NTP failed to document:(1)Absence of recent abuse of drug (narcotic or non-narcotic), including alcohol.(2)Regular narcotic treatment program attendance.(3)Absence of serious behavioral problems at the narcotic treatment program.(4)Absence of known recent criminal activity.(5)Stability of the patient ' s home environment and social relationships.(6)Length of time in comprehensive maintenance treatment.(7)Assurances that take-home medication can be safely stored within the patient ' s home.(8)Whether the rehabilitative benefit to the patient derived from decreasing frequency of attendance outweigh the potential risks of drug diversion.The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
A very thorough review process already is in place with respect to granting of take home privileges. Furthermore take home privileges are not afforded to transfers (regardless of their status at another facility) except in extreme circumstances (i.e., medical disability). The need for clearly documenting the rationale for granting take home privileges to transfer patients (in those rare instances in which they are granted) has been re-affirmed with program physicians. Chart audit, to be conducted by the Program Coordinator, will be the method by which compliance with the standard will be ensured. An exception form has been placed in the chart of patient #8. |
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 an average of 2.5 hours of psychotherapy per month during the patient's first 2 years.The findings include:Twelve patient records were reviewed on December 1, 2015. Eight of which were required to receive at least 2.5 hours of psychotherapy. The facility failed to provide 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in patient records, # 2, 5, 6, and 9.Patient # 2 was admitted to the program on September 21, 2015. The facility failed to provide an average of 2.5 hours of psychotherapy per month for patient # 2 for the following months; October 2015 and November 2015.Patient # 5 was admitted to the program on June 11, 2015. The facility failed to provide an average of 2.5 hours of psychotherapy per month for patient # 5 for the following months; August 2015, September 2015, October 2015 and November 2015.Patient # 6 was admitted to the program on April 30, 2015. The facility failed to provide an average of 2.5 hours of psychotherapy per month for patient # 6 for the following months; July 2015, August 2015, September 2015, October 2015 and November 2015.Patient # 9 was admitted to the program on July 29, 2014. The facility failed to provide an average of 2.5 hours of psychotherapy per month for patient # 9 for the following months; August 2015, September 2015, October 2015 and November 2015.The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Clinical staff have been trained via an inservice session conducted by the Facility Manager/Division Director on the need to provide minimally 2.5 hours of care in the first two years of treatment. A key component of this inservice was the utilization of motivational interviewing strategies as a means for promoting engagement and attendance. Random review of all clinical records, including real-time feedback to clinical staff, to be overseen by the Coordinator of Treatment and Training, will ensure compliance with the standard. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 in treatment after 4 years with at least 1 hour of group or individual psychotherapy every 2 months.The findings include:Twelve patient records were reviewed on December 1, 2015. One of which was required to receive at least 1 hour of group or individual psychotherapy every 2 months, specifically patient # 8.Patient # 8 was admitted to the program on July 29, 2015. The facility failed to provide at least 1 hour of group or individual psychotherapy every 2 months for patient # 8. Based on progress notes and the record of services provided, patient # 8 received counseling on July 29, 2015 and 2 half hour sessions for the month of November 2015 at which time the counselor documented that patient was requested to come in to discuss treatment. The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
It shall be the responsibility of the Program Coordinator and Clinical Supervisor(s) to ensure clinicall staff compliance with the requirement of minimally one hour of contact every two months for individuals in treatment greater than four years. This will be accomplished via a training session to be conducted within the next wto weeks. Periodic random review of the records of those in treatment over four years will ensure compliance with the standard. |
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 physical plant inspection, the facility failed to secure patient records within locked storage containers and maintain the confidentiality of patient identity and records.The findings include:A physical plant inspection was conducted on December 1, 2015. The facility failed to secure patient records within locked file cabinets in at least 3 different locations.1st floor office - The facility failed to ensure that patient records were maintained within locked file cabinets in the unassigned office that is used by various students.1st floor multi-purpose room - The facility failed to maintain patient records within locked file cabinets in the multi-purpose room which contains a fax machine and other office equipment and supplies and is accessible by all staff.2nd floor - The facility failed to maintain patient records within the exam room in locked file cabinets. In addition, a stack of patient records were observed unsecured on a counter in the exam room.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It shall be the responsibility of the Facility Director and the Program Coordinator to ensure compliance with the standard. Staff have been trained on the need for ensuring that patient files are kept in locked file cabinets when not being used. To assist in maintaining compliance, discharged records are no longer stored in the unassigned office and have been moved to the "multipurpose room" which is now locked at all times. Random review of clinical offices to be conducted by the program coordinator and facility director will ensure compliance. |