INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2013 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" completed by each facility in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Reports" for the two facilities that make up the Project were reviewed. The "Staffing Requirements Facility Summary Reports" completed by the facilities' on December 17, 2013 and December 18, 2013 listed a combined total of 18 counselors and 3 staff identified as Clinical Supervisors. However, one of the staff identified as a clinical supervisor had 13 clients on her caseload and one of the other staff identified as a clinical supervisor also serves as a facility director.
The total number of drug and alcohol counseling hours per week provided by the Project equated to 17.773 FTE counselors within the Project, and therefore the project was required to have at least 2 full-time clinical supervisors. The "Staffing Requirements Facility Summary Reports" only identified 1 full-time clinical supervisor for the Project.
This is a repeat citation. The facility was cited on January 16, 2013 for noncompliance with this standard.
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Plan of Correction
It is the responsibility of the facility director(s) to ensure adequate supervisory oversight relative to the number of the project's clinical staff. Our project now has 1 full-time clinical supervisor for every eight full-time counselor. At present, there are two full-time clinical supervisors within the project. Caseloads of clinical supervisors will be monitored closely by the facility director(s) to esnure that they do not exceed the maximum number of 5 rendering us with one full-time clinical supervisor for every 8 counselors. |
705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. In addition, the facility failed to provide pressurized hot water in each bathroom.
The findings include:
A physical plant inspection was conducted with a clinical supervisor on December 17, 2013 at approximately 9:30am. The facility has two client bathrooms, one male and one female, on the first floor. These bathrooms are located next to the security guard station. At the time of inspection, there were no paper towels in both the male and female bathrooms.
Additionally, the facility has two client bathrooms, one male and one female, on the second floor. At approximately 9:45am, it was observed that the second floor client bathrooms (both male and female) did not have any pressurized hot water.
The Clinical Supervisor confirmed both sets of findings. The Facility Director confirmed both sets of findings after a discussion.
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Plan of Correction
It is the responsibility of the Facility Director to ensure compliance with the cited standard. Electric hand dryers have been purchased and will be installed by 1/31/14 in the male and female bathrooms on the first and second floors. The hot water heater that serves the client bathrooms on the second floor will be replaced by 1/31/14. As a result, the second floor client bathrooms (both male and female) will have pressurized hot water by 1/31/14. The Program Coordinator and/or Facility Director will make sure that facility bathrooms have either paper towels or operable electric hand dryers at all times as well as pressurized hot water bathroom at all times. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in six of seven client records reviewed.
The findings include:
On December 17, 2013, seven client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in six of seven records reviewed, specifically, client records # 2, 4, 5, 8, 9, and 10.
Client # 2 was admitted October 3, 2013. The individual treatment and rehabilitation plan was completed November 5, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 17, 2013.
Client # 4 was admitted August 29, 2013. The individual treatment and rehabilitation plan was completed September 9, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 17, 2013.
Client # 5 was admitted June 28, 2013. The individual treatment and rehabilitation plan was completed September 13, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 17, 2013.
Client # 8 was admitted May 16, 2013. The individual treatment and rehabilitation plan was completed June 10, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 17, 2013.
Client # 9 was admitted May 30, 2013. The individual treatment and rehabilitation plan was completed July 10, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 17, 2013.
Client # 10 was admitted June 17, 2013. The individual treatment and rehabilitation plan was completed July 10, 2013, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of December 17, 2013.
The findings were presented to the facility director and clinical supervisors on December 17, 2013 at approximately 3:15 P.M.
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Plan of Correction
Several of the charts reviewed did not document proposed support services in the treatment and rehabilitation plans. Recognizing the significance of support services in the recovery process, it is important that treatment plans indicate that the counselor has discussed support services with the patient. The facility director will discuss support services with the counselor, and during the treatment plan review process, determine that treatment plans document the recommendation of support services. (as needed). It will be the responsibility of the Facility Director to ensure compliance via chart review conducted during supervision. Existing treatment plans for clients 2,4,5,8,9 & 10 will be ammended to include support services (as needed) - this will be overseen by the 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 client records, the project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in one of three records reviewed.
The findings include:
On December 17, 2013, three client records requiring documentation that the project notified the client in writing of a decision to involuntarily terminate the client at the project were reviewed. The project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in one of three records reviewed, specifically client record # 13.
Client # 13 was admitted November 8, 2011 and involuntarily terminated June 3, 2013. The facility was required to give client # 13 notification in writing of a decision to involuntarily terminate client # 13 from the project. However, client record # 13 did not include documentation of the project notifying client # 13 of a decision to involuntarily terminate client # 13 from the project as of December 17, 2013.
The findings were presented to the facility director and clinical supervisors on December 17, 2013 at approximately 3:15 P.M.
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Plan of Correction
It is the responsibility of the senior administrative personnel (Facility Director, Program Coordinator, Clinical Supervisor) to ensure that written attempts are made to notify clients who are being involuntarily terminated from treatment. The need for written notification has been reviewed with the staff on January 6, 2014. Ongoing review of the clinical record of clients prior to discharge fom treatment will ensure future compliance with the standard. Client #13 will be notified in writing by counseling personnel - this will be overseen by the Program Coordinator. |