INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4-6, 2019, 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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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
The facility fire drill records were reviewed during the on-site inspection.
The fire drill record for the fire drill conducted on August 31, 2018, does not document the evacuation routes used during the fire drill.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
All fire drill forms will be completed by the administrative assistant. Following the completion of a fire drill and the completion of the documentation, the Program Director will review to ensure that all necessary requirements of the form have been completed fully for 6 months to ensure that this citation error has been rectified. |
715.16(c)(2)(i-iv) LICENSURE Take-home previliges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(2) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 2 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
The facility failed to ensure that all of its patients met the mandatory requirements for the take-home supply of methadone that the facility authorized for the patients.
Patient #2 was admitted for treatment on September 8, 2016. The patient was not eligible for three consecutive days of take-home methadone until September 8, 2018, but the patient was authorized for a 3-day take-home supply of methadone on January 11, 2018. The authorization for the patient's supply of take-homes continued up to the time of the on-site inspection.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
All therapists and nursing staff have been informed of the policy and will ensure when helping a client apply for take home bottles, that they do not receive 3 days in a row until they have been in treatment for 2 years.
Clinical Supervisor, Nurse Coordinator, and Medical Director will ensure this is being followed. Nursing staff will double check admission date when entering orders for THB into the system to ensure they do not have 3 consecutive days in a row until the alloted time of 2 years in treatment. |
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
The facility failed to ensure that it notified transferring narcotic treatment programs that the patients transferred were dosed at the receiving facility.
Patient #3 transferred into the facility from another narcotic treatment program on October 17, 2018. There was no documentation that the receiving facility notified the transferring facility that the patient was dosed.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Care Coordination Manager will meet with her staff on 3/14/19 to ensure that when admitting a patient as a transfer, a letter is sent to the referring clinic. This letter will include all required components: confirmation and date of admission and confirmation of medication received.
Care Coordination Manager will conduct random chart audits to ensure this is being completed. |
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
The facility failed to ensure patient confidentiality in 1 of 9 patient records reviewed during the on-site inspection.
At the time of the on-site inspection, there was letter in patient #3's patient file that identified another patient of the facility by using the other patient's full name. The letter was addressed to the other patient's attorney.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
All staff involved with charting were informed of the citation and the importance of ensure filing is correct.
Therapists are ultimately responsible for their clinic charts for their caseload. They will conduct a minimum of quarterly audits to ensure all filing is complete and filed appropriately. Additionally, Clinical Supervisor and Lead Therapist will conduct random chart audits to ensure that documentation is filed correctly. |