INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and NTP monitoring conducted on December 6-7, 2016 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.
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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 facility's Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training for employee #3.
Employee # 3 was hired as a counselor on June 8, 2015. HIV/AIDS and TB/STD trainings were due to be completed no later than June 8, 2016. Employee #3 failed to have documented in their personnel file the required HIV/AIDS training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HIV training was only offered on 6/8/15 (the start date of the employee). By the time she was hired, 9/9/2015 (full) and 4/18/2016 (full). Due to not being able to find an available training, we decided to host our own. However because of the 50 mile, 90 day rule and the availability of the trainer 7/22/16 was the first time we were able to offer the training. This individual employee completed the training on 7/22/16.
The Administrative Assistant will continue to schedule new employees as soon as possible for training dates. Any time this date falls outside of the mandated deadlines, the Administrative Assistant will notify the Program Director. The Administrative Assistant will continue to use an excel spreadsheet database to ensure that all employee's mandated training's are completed as quickly as possible.
Person's Responsible: Administrative Assistant; Program Director |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill record, the facility failed to document alternate exits routes. The fire drill record was reviewed from January 2016 through October 2016.
The facility documented the same exit route during fire drills for the following months; October, June, May, April, March, February and January. The month of July the facility failed to mark what exit route they used during the fire drill.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will work with Administrative Assistant to plan fire drills for 2017. The planning of this will ensure that we are including morning, middle of the day, and afternoon fire drills. Additionally, we will plan to use different exits during drills to ensure that all exits are used throughout the year. Program Director will review all fire drill logs to ensure that the above is being met. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records on December 6-7, 2016, the facility failed to document monthly drug-screenings urinalysis in patient record, #6.
Patient #6 was admitted on January 14, 2013. The last urinalysis was taken October 14, 2016.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The urinalysis for November for patient #6 was previously misfiled. The urinalysis was collected on 11/9/16. This citation was not reviewed with staff during the audit or during the exit interview.
Currently, nursing staff and counselors track to ensure all patients have received monthly drug screen testing. This procedure will continue. Additionally, during random quarterly audits, the Clinical Supervisor will ensure all drug screens are in the chart and filed in the correct location. |
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 on December 6-7, 2016, the facility failed to show documentation of semi-reviews of the patient's dosage in patient records, #17 and 19.
Patient #17 was admitted on June 19, 2014 and discharged on November 15, 2016. The last semi-review was documented on December 11, 2015.
Patient #19 was admitted on October 21, 2015 and discharged on August 12, 2016. As of the date of the licensing inspection there were no semi-reviews of the patient's dosage.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Semi-reviews of patient dosage are completed by primary counselor and reviewed with Medical Director. Quarterly chart audits will be completed by the Clinical Supervisor to ensure documented dose changes are completed and filed.
Person(s) responsible: Clinical Supervisor, Medical Director, and Primary Counselor
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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 on December 6-7, 2016, the facility failed to provide each patient an average of 2.5 hours of psychotherapy, with at least 1 hour of individual sessions, per month during the patient's first 2 years of treatment in patient records, #1, 3 and 7.
Patient #1 was admitted on August 30, 2016. The facility failed to document individual sessions for the month of November 2016.
Patient #3 was admitted on June 26, 2016. The facility failed to document group or individual sessions for the month of November 2016. Additionally, the facility documented an 1/2 individual session in October 2016 and in August 2016 the facility documented a 1 hour group session and a 1 hour individual session.
Patient #7 was admitted on June 7, 2016. The facility documented 1 individual session for 1 hr and no group sessions in November 2016 and the same for October 2016. Lastly, the facility documented 2 individual sessions both an hour long with no group sessions for the month of September.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All deficiencies will be reviewed with individual counselors during bi-weekly individual supervision. Each counselor has developed tracking grids/systems that list all required documents and time frame for completion. The tracking system will be included in bi-weekly individual supervision to ensure that all patients receive the required number of monthly clinical services.
Additionally, the regulations will be reviewed in group supervision.
Clinical Supervisor will complete random quarterly chart audits to ensure hours are being met.
Time frame for completion: Immediate
Person(s) responsible: Clinical Supervisor and Primary Counselor
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records on December 6-7, 2016, the facility failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in patient record, #10.
Patient #10 was transferred to the facility on July 12, 2016.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The nurse who completes the initial dose for a transfer patient will immediately complete a dose confirmation and send to her previous clinic. The dose confirmation will be kept in the patients chart.
Person responsible: Medicating nurse and Nurse Coordinator will ensure this is completed. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records on December 6-7, 2016, the facility failed to provide documentation of the patient's initial physical examination in patient record, #2.
Patient #2 was admitted on July 12, 2016.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nursing staff will audit all new patient charts to ensure all documents are present, using a checklist. Any items that are not present we will include an explanation regarding the time-line in which we will receive the document. Any individuals who are missing a physical upon admission from the hospital will have one completed within 7 days of beginning at Family Center.
Persons responsible: Nursing staff and Nurse Coordinator. |
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 on December 6-7, 2016, the facility failed to provide documentation of the patient's annual physical examination in patient record, #4.
Patient #4 was admitted on March 23, 2011. The last annual physical examination documented was October 30, 2015.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Patient #4 had her physical completed at Jefferson on 1/5/17.
Insurance will not allow us to schedule an annual within 365 days of the previous one, so it has to be on or after the date giving us a small window to have the physical completed to remain in compliance.
Nurse will send a weekly audit to update any out of compliance individuals to the Nurse Coordinator. It will be determined appropriate action at that time (whether that is a loss of privileges or taper for continued non-compliance, etc.).
Persons responsible: Nursing staff and nurse coordinator |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of patient records on December 6-7, 2016, the facility failed to document an aftercare plan in patient record, #19.
Patient #19 was admitted on October 21, 2015 and was successfully discharged on August 12, 2016.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Discharge packets will be created by the Clinical Supervisor to help counselors have all necessary paperwork in one location. Once the packet is completed, it will be presented to counselors in group supervision. The aftercare plan will be completed as soon as a patient begins to discuss leaving treatment. The aftercare plan can then be adapted as needed.
The primary counselor will be responsible for completing paperwork. Clinical Supervisor must sign paperwork before providing a copy to the patient and therefore can ensure the aftercare plan is completed prior to discharge. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records on December 6-7, 2016, the facility failed to document an annual evaluation in patient record, #17.
Patient #17 was admitted on June 19, 2014 and was discharged on November 15, 2016. The last annual evaluation was documented on June 9, 2015.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All deficiencies will be reviewed with individual counselors during bi-weekly individual supervision. Each counselor will develop a tracking grids/systems that list all required documents and time frame for completion. The tracking system will be included in bi-weekly individual supervision to ensure that all paperwork is current and completed.
Additionally, the Clinical Supervisor will complete random quarterly chart audits to ensure all paperwork is completed and filed.
Person responsible: Counselor; Clinical Supervisor |
711.91(b)(4) LICENSURE Consent to Treatment
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records and converstions with facility staff during the licensing inspection on December 6-7, 2016. The facility failed to have in place a consent to treatment in the following client records, 1 through 19.
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Plan of Correction
A consent to treatment will be added to the current consent to MAT form that is being used. All new patients will begin signing this form immediately. For current patients, the administrative assistant and intake coordinator will begin to review the form with patients individually, have the form signed, and file the forms in patient charts.
This form will be added to the intake packet to ensure this deficiency does not occur again.
Persons responsible: Intake Coordinator, Nurse Coordinator |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on December 6-7, 2016, the facility failed to document a psychosocial evaluation in client records, #1, 2, 3, 7, 8, 9, 10 and 11. The psychosocial evaluations were more historical than evaluative.
Client #1 psychosocial evaluation was documented on 9/21/16
Client #2 psychosocial evaluation was documented on 8/4/16
Client #3 psychosocial evaluation was documented on 7/8/16
Client #7 psychosocial evaluation was documented on 7/6/16
Client #8 psychosocial evaluation was documented on 6/1/16
Client #10 psychosocial evaluation was documented on 10/18/16
Client #11 psychosocial evaluation was documented on 9/30/16
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor and Program Director will update the assessment page of the psychosocial document to clearly state an assessment is needed. Clinical Supervisor will review this with all counselors in group supervision. Counselors will immediately make the change following group supervision.
Counselors will present their first two or three psychosocial assessments to Clinical Supervisor for review before filing to ensure the evaluation is an assessment and not historical. After this, Clinical Supervisor will review psychosocial assessments during random quarterly chart audits to ensure counselors continue to make an assessment and do not return to historical evaluations. |
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 on December 6-7, 2016, the facility failed to document the treatment plan update every 60 days in client records, #2, 3, 5, 8, 10, 15, 16, 17 and 19.
Client #2 was admitted on July 12, 2016. The last treatment plan update was documented on October 5, 2016. The next treatment plan update was to be documented by December 5, 2016. The facility failed to document a treatment plan update as of the date of the licensing inspection.
Client #3 was admitted on June 26, 2016. The comprehensive treatment plan was documented on July 8, 2016. The treatment plan update was due by September 8, 2016. The treatment plan update was documented on September 16, 2016.
Client #5 was admitted on December 5, 2014. The last treatment plan update was documented on June 30, 2016. The next treatment plan update was to be documented by August 30, 2016. The treatment plan update was documented on September 7, 2016.
Client #8 was admitted on May 20, 2015. The comprehensive treatment plan was documented on June 10, 2016. The treatment plan update was due by August 10, 2016. The treatment plan update was documented on August 17, 2016 and the next one was documented on October 19, 2016.
Client #10 was admitted on July 12, 2016. The comprehensive treatment plan was documented on August 12, 2016. The treatment plan update was due by October 12, 2016. The facility failed to document a treatment plan update as of the date of the licensing inspection.
Client #15 was admitted on January 16, 2010 and discharged on August 8, 2016. The last treatment plan update was documented on April 27, 2016. The next treatment plan update was to be documented by June 27, 2016. The facility failed to document a treatment plan update as of the date of the licensing inspection.
Client #16 was admitted on August 3, 2014 and discharged on September 9, 2016. The last treatment plan update was documented on June 2, 2016. The next treatment plan update was to be documented by August 2, 2016. The facility failed to document a treatment plan update as of the date of the licensing inspection.
Client #17 was admitted on June 19, 2014 and discharged on November 15, 2016. The last treatment plan update was documented on January 29, 2016. The next treatment plan update was to be documented by March 2, 2016. The facility failed to document a treatment plan update as of the date of the licensing inspection.
Client #19 was admitted on October 21, 2015 and discharged on August 12, 2016 . The last treatment plan update was documented on May 18, 2016. The next treatment plan update was to be documented by July 18, 2016. The facility failed to document a treatment plan update as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Each counselor will develop a tracking grids/systems that list all required documents and time frame for completion. The tracking system will be included in bi-weekly individual supervision to ensure that all patients treatment plans are updated every 60 days.
Additionally, the regulations will be reviewed in group supervision. During this time counselors will explore and share ways of ensuring treatment plans are completed on time especially with those clients who are missing individual sessions.
Client #2's treatment plan was completed in session on 12/6/16.
Client #10 was discharged on November 29th, 2016. Between October 12th and her discharge date, client met with Clinical Supervisor for sessions. Clinical Supervisor was unable to complete an updated treatment plan due to client planning to leave the program. All sessions were focused on discharge.
Clinical Supervisor will complete random quarterly chart audits to ensure hours are being met.
Person Responsible: Counselor and Clinical Supervisor |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
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:
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Observations
Based on a review of client records on December 6-7, 2016, the facility failed to obtain an informed and voluntary consent in client records, #3, 4, 6, 8, 12, 15, 16, 17, 18 and 10. Additionally, the facility exceeded 4 PA code 255.5 in client record #3.
Client #3 was admitted on June 26, 2016. A Letter dated 8/19/16, was mailed out to the client's employer giving identifying information to the employer about the client. Additionally, the following progress note was reviewed where the counselor gave identifying information about the client to the client's employer on 8/6/16. The facility also failed to documented on the consent to release form what was being release for the client's employer dated 7/27/16.
Client #4 was admitted on March 23, 2011. The consent to release form for an government agency documented on 3/4/16 showed that the witness signed the consent form on 3/4/16 and the client signing it on 3/14/16.
Client #6 was admitted on January 14, 2013. The case manager documented in their progress notes that they uploaded a letter to a funding source on October 17, 2016, August 15, 2016 and June 29, 2016. The facility failed to have a consent to release documented for the funding source.
Client #8 was admitted on May 20, 2016. The facility failed to document what was being release on three consent to release forms for three different treatment providers all dated August 25, 2016.
Client #12 was admitted on November 23, 2016. The facility failed to document the purpose for the release and what was being release on a consent to release to an government agency dated November 23, 2016.
Client #15 was admitted on January 16, 2010 and discharged on August 8, 2016. A consent to release dated July 18, 2016 for a person did not have documented on the consent what was being release. A consent to release dated July 15, 2016 for an government agency did not have documented on the consent what was being release and the purpose for the release. A consent to release dated July 12, 2016 for a treatment provider did not have documented on the consent what was being release. Lastly, a consent to release dated May 28, 2016 for the client's friend did not have documented on the consent what was being release.
Client #16 was admitted on August 3, 2014 and discharged on September 9, 2016. A consent to release dated August 4, 2016 for a treatment provider did not have documented on the consent what was being release. A consent to release dated Ju;y 1, 2016 for an agency did not have documented on the consent what was being release. A consent to release dated June 30, 2016 to the client's PCP did not have document on the consent what was being release. Lastly, a consent to release dated June 7, 2016 for the client did not have on the consent what was being release.
Client #17 was admitted on June 19, 2014 and discharged on November 15, 2016. A consent to release dated August 15, 2015 to a person did not have documented what was being release on the consent form. Additionally, a letter was sent out on October 14, 2016 addressed "To Whom It May Concern".
Client #18 was admitted on November 4, 2013 and discharged on June 23, 2016. The following treatment plans dated June 1, 2016, April 18, 2016 and January 19, 2016 did not have the date the client signed the consent forms. Additionally, identifying information was sent out to an agency dated 7/27/16, but no consent to release documented for this agency.
Client #19 was admitted on October 21, 2015 and discharged on August 12, 2016. A consent to release dated July 13, 2016 to a criminal justice agency did not have documented on the consent the expiration date and what was being release. Additionally, a consent to release dated May 12, 2016 for the client's lawyer did not have documented on the consent the expiration date and what was being release.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All clinical staff received Confidentiality Practical Applications training in November 2016 where it was taught that information cannot be disclosed to employers. Moving forward, staff will only communicate what is permitted by 255.5 with employers.
Information on properly completing a consent form will be provided to all staff. This mini-training will be conducted by the Clinical Supervisor and will consist of ensuring that all information is completed (purpose, what is being released, accepting/not accepting a copy). Additionally, after the client signs the date will be checked to ensure the client dated the correct date. Staff will also be reminded that all letters going out need to be directed to a person and not "to whom it may concern". During quarterly chart audits, counselors will ensure all consent forms are properly filed and not expired. Clinical Supervisor will also check during random quarterly audits.
Client #3. The current consent form will be voided. Primary counselor will complete new consent form with client to ensure only restricted information is being shared by 1/20/17.
Client #4. The current consent form will be voided. Primary counselor will complete a new consent form with client and ensure it is properly dated by all by 1/20/17.
Client #6. The consent was previously signed but was misfiled in the chart. The consent form was immediately moved to the correct location in the chart.
Client #8. These consent forms were utilized to contact the clinic to determine if they had openings. Before information is sent to a transferring clinic, an additional consent form will be utilized to indicate what information is being sent over. A new consent form will be created for individuals who are interested in transferring from Family Center. This new consent form will indicate what information is being released. This consent form will be created by 1/20/17.
Client #12. The consent form will be voided. A new consent form will be completed with client and primary counselor indicating the purpose of the consent form. This will be completed by 1/20/17.
Client #15 - 19. Have been discharged so there is no ability to correct the consent forms.
Persons responsible: Counselors and other clinical staff, 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 a client records on December 6-7, 2016, the facility failed to show documentation that the client was offered a copy of their consent in client records, #3, 4, 8, 15, 16 and 18.
Client #3 was admitted on June 26, 2016. Consent to release to a government agency dated July 29, 2016. A consent to release to a treatment provider dated September 23, 2016 and a consent to release to the client's employer dated July 27, 2016.
Client #4 was admitted on March 23, 2011. Consent to releases all dated 3/4/16 for a government agency, the client's funding source, a lab, the client emergency contact, transportation and a friend.
Client #8 was admitted on May 20, 2016. Consent to releases all dated August 25, 2016 to three treatment providers and one consent to release dated September 23, 2016 also for a treatment provider.
Client #15 was admitted on January 16, 2010 and discharged on August 8, 2016. Consent to release to a government agency dated July 15, 2016. A consent to release to a treatment provider dated July 12, 2016 and a consent to release for a friend dated May 28, 2016.
Client #16 was admitted on August 3, 2014 and discharged on September 9, 2016. Consent to release dated June 30, 2016 for the client's PCP and a consent to release dated June 7, 2016 for the client.
Client #18 was admitted on November 4, 2013 and discharged on June 23, 2016. Consent to releases dated June 1, 2016, April 18, 2016 and January 19, 2016 for three treatment providers.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Information on properly completing a consent form will be provided to all staff. This mini-training will be conducted by the Clinical Supervisor and will consist of ensuring that all information is completed (purpose, what is being released, accepting/not accepting a copy). Additionally, after the client signs the date will be checked to ensure the client dated the correct date. Staff will also be reminded that all letters going out need to be directed to a person and not "to whom it may concern". During quarterly chart audits, counselors will ensure all consent forms are properly filed and not expired. Clinical Supervisor will also check during random quarterly audits.
Client #3, 4, 8, 15, 16, and 18. All current consent forms will be voided. Clients will meet with individual counselors and complete a new consent form. Each form will note if the individual accepted or rejected a copy of the consent form. These will be updated by 1/20/17.
Persons responsible: Counselors and other clinical staff, Clinical Supervisor |
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of two administrative discharges on December 7, 2016, the facility failed to document a notice of termination in client record #16.
Client #16 was admitted on August 3, 2014 and administratively discharged on September 9, 2016.
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Plan of Correction
Discharge packets will be created by the Clinical Supervisor to help counselors have all necessary paperwork in one location. Once the packet is completed, it will be presented to counselors in group supervision.
The termination letter will be completed and attached to the order to be signed by the medical director prior to the start of an administrative taper. Orders for administrative taper that do not include the termination letter will be returned to the counselor and will not begin until all paperwork is included.
Persons responsible: Primary Counselor, Nursing Staff, Medical Director
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