INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on December 12, 2023 through December 13, 2023 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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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
Based on a review of the facility's February 2023 through November 2023 fire drill logs, the facility failed to ensure that their written fire drill logs included which exit routes were used during fire drills conducted during the months of February 2023, September 2023, and October 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager has been instructed that all corresponding questions need to be answered on the Record of Fire Drill form every time a fire drill is conducted.
A fire drill was conducted on 12/08/2023, and all questions on the form, including exit routes utilized, have been completed.
The Business Manager will audit the fire drill logs on a random basis, few times a year, to ensure compliance. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's February 2023 through November 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts. The facility's hours of operation are Monday through Friday from 6:40AM to 5:00PM and Saturdays and Sundays from 8:30AM to 11:30AM. None of the drills conducted during the reviewed period were completed during the facility's morning hours of operation.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager was instructed to conduct fire drills at various times during the business hours.
A fire drill was conducted on12/28/2023 at 10:30am.
All fire drills will be conducted at different times moving forward.
The Business Manager will check fire drill logs quarterly to ensure that fire drills are conducted at different times of the day and different days of the week. |
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for ensuring that each patient receive an annual physical examination, which is given by the narcotic treatment program and includes an annual reevaluation by the narcotic treatment physician, were submitted and approved by the Department for December 1, 2021 through December 2, 2021 and January 10, 2023 through January 11, 2023 annual licensing inspections. Failure to ensure that each patient received an annual physical examination was again found to be a deficiency in the December 12, 2023 through December 13, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new tracking system has been created to prevent further deficiencies in this area.
The Lead Nurse Practitioner will review the list of annual physical exam due dates on a weekly basis and will ensure annual appointments for physicals exams are scheduled in a timely manner in order to stay in compliance.
The first appointment for an annual physical evaluation will be scheduled with the patient a minimum of 60 days prior to the annual physical due date. The Lead LPN will track if the individual attends or misses the appointment and will document all missed appointments in the chart. With weekly tracking of appointments, a missed appointment will be caught soon enough to reschedule prior to the deadline. After the 2nd missed appointment, the individual will be placed on hold daily (M-F) until a provider is able to see them to complete the annual physical. All missed physical appointments will be mentioned in the weekly treatment team meeting so clinical staff are aware and can support medical staff on attendance of this appointment including identifying barriers to attending the appointments.
All physicians, NP, and nurses will be informed of this new change in scheduling and attending appointments through a memo sent by the Nurse Supervisor.
The Nurse Supervisor will conduct random chart audits to ensure compliance |
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 program failed to document, prior to administration of an agent, the results of a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been dependent for at least a year prior to admission for maintenance treatment, in one of two applicable patient records reviewed.Patient #7 was admitted on October 4, 2023 and was discharged on November 22, 2023. There was no documentation of a face-to-face determination in the record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program medical provider will conduct a face-to-face determination with clients that are admitted to the program using the Evidence Suggesting Current Substance Use form.
The form will be revised to add questions that assess for current physiological dependence on opioids, as well as physiological dependence on opioids over the past 12 months. The form will be completed by the physician prior to initiating methadone to new patients.
The encounter will be documented in the EHR.
For the clients who are transferred to the program from another OTP, or the clients who have been referred by the hospital following their stabilization (usually pregnant women), the transfer and/or referral paperwork will be reviewed by the physician. The paperwork will be uploaded in the EHR.
The Clinical Director will conduct new admission chart audits on a random basis to ensure compliance with the requirement.
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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, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient, in two of four applicable patient records reviewed. Patient #5 was transferred in and admitted on May 3, 2023 and was still active at the time of the inspection. There was no documentation in the record indicating that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given. Patient #7 was transferred in and admitted on October 4, 2023 and was discharged on November 22, 2023. There was no documentation in the record indicating that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Care Coordination Manager will complete the Letter of Admission (confirming client admission and the initial dose). The Letter of Admission will be faxed to transferring narcotic program.
The Letter of Admission and the fax confirmation sheet will be uploaded in client chart in the EHR.
The completion of the task will be documented in the client EHR.
The Clinical Director will be notified all of all new admissions through EHR. The Clinical Director will conduct random audits of new admission charts to ensure this documentation is completed for transferring individuals. |
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, the narcotic treatment program failed to document, in the record, the results of an initial intake physical examination in one of four applicable patient records reviewed. Patient #7 was admitted on October 4, 2023 and was discharged on November 22, 2023. There was no documentation of an initial intake physical examination in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Supervisor will create a system for scheduling and tracking the initial physical examination for new admissions.
Upon admission, the intake staff who completed the intake will alert the provider that the client needs to be scheduled for an initial physical evaluation within 14 days.
Care Coordination Manager (CCM) will check the provider' schedule at the end of the day to identify clients who did not present for initial physical evaluation, and will ensure the appointment is rescheduled within 24 business hours.
If the client is a transfer from another OTP or a referral from a hospital following stabilization, their referral paperwork will be uploaded in the EHR for the physician's review.
The Lead NP will track the initial physical evaluations.
The Clinical Director will conduct random chart audits to ensure compliance. |
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 narcotic treatment program failed to document the results of an annual physical examination, which is given by the narcotic treatment program and is to include an annual reevaluation by the narcotic treatment physician, in two of three applicable patient records reviewed.Patient #3 was admitted on November 10, 2020 and was active at the time of inspection. There was no documentation of an annual physical exam in the record at the time of the inspection.Patient #6 was admitted on December 18, 2020 and was discharged on April 4, 2023. There was no documentation of an annual physical exam in the record at the time of the inspection.This is a repeat citation from the December 1, 2021 through December 2, 2021 and January 10, 2023 through January 11, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lead LPN will create a tracking system. The Lead LPN will review the list of annual physical exam due dates on a weekly basis and will ensure annual appointments for physicals exams are scheduled in a timely manner in order to stay in compliance.
The Nurse Supervisor will conduct random chart audits to ensure compliance. |
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, the narcotic treatment program failed to document, in the record, an annual evaluation of each patient's status completed by the patient's counselor and reviewed, dated, and signed by the medical director in two of four applicable patient records reviewed. Patient #3 was admitted on November 10, 2020 and was active at the time of inspection. There was no documentation of an annual clinical evaluation for the reviewed period in the record at the time of the inspection.Patient #6 was admitted on December 18, 2020 and was discharged on April 4, 2023. There was no documentation of an annual clinical evaluation for the reviewed period in the record at the time of the inspection.This is a repeat citation from the January 10, 2023 through January 11, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will instruct counselors to direct all annual clinical case conferences to the medical director, or the designee, for review and signature.
Counselors will be informed of this in group supervision on 1/17/2024.
The clinical case conference includes review of 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.
The medical director or designee will review and sign the annual case conferences.
The Clinical Director will conduct random chart audits to ensure compliance .
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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 four applicable records reviewed. Client #5 was admitted on May 3, 2023 and was still active at the time of the inspection. There was no follow-up information documented in the record as of the date of the inspection. Client #7 was admitted on October 4, 2023 and was discharged on November 22, 2023. There was no follow-up information documented in the record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director reviewed the requirement for follow up with clients following discharge.
The Lead Crisis Counselor's team is tasked with this requirement.
The Lead Crisis Counselor will develop a tracking system to ensure discharge follow-up is completed and documented in the EHR. |