INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10 and 11, 2008 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 and a plan of correction is due on January 15, 2008.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and a conversation with the facility director, the facility failed to document monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position.
Findings:
The personnel records were reviewed on December 10, 2008. The conversation with the facility director was conducted on December 9, 2008. The facility did not document monthly meetings with their supervisor, #3, to discuss her duties and performance for the first six months of employment in that position. The clinical supervisor was hired on September 2, 2008.
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Plan of Correction
The Program Director has initated consistent supervisory notes with the Clinical Supervisor on a monthly basis. All notes are documented and retained in the supervisory chart. In order to provide a consistent 6 month supervisory record, notes commenced with the date of site visit
Person(s) responsible: Program Director
Timeframe for completion: Immediate
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel records, the facility failed to document an assessment of staff training needs in four of nine personnel records reviewed.
Findings:
Nine personnel records were reviewed on December 10, 2008. An assessment of staff training needs was required in seven personnel records. The facility did not document an assessment of staff training needs in four of seven personnel records reviewed, #5, 7, 8 and 9.
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Plan of Correction
An Orientation Assessment Training Needs sheet has been designed and implemented for all new hires. The immediate supervisor will be responsible to complete this form, with the new employee, within 30 days of hire. The supervisor will then make a copy of this document for the Administrative Assistant to file in the staff's training folder. This orientation assessment training needs form will be included in the "Supervisor's Checklist" for all new hires. A copy of the checklist will be submitted to the Program Director for further monitoring.
Person(s) responsible: Immediate Supervisor, Administrative Assistant, and the Program Director.
Timeframe for completion: Within 30 days
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of nine personnel records, the facility failed to document a mechanism to collect feedback on completed training, provided by the facility, as well as outside trainers, in three of five personnel records reviewed.
Findings:
Nine personnel records were reviewed on December 10, 2008. Documentation of feedback on completed training was required in five personnel records. The facility did not document feedback on completed training in three of five personnel records reviewed, #1, 2 and 8.
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Plan of Correction
The training flow sheet has been amended to include a column for receipt confirmation the training sheet and, when possible, a certificate of training, including the hours. Since training opportunities are approved by supervisors, then supervisors are responsible to monitor submission of all training documents. Once received, a copy will be placed in the staff's training folder. Quarterly audits are completed by the Administrative Assistant and results reported to the supervisors and the Program Director. Any missing training sheets/certificates are missing, staff will be responsible to submit the missing sheets immediately. Also, all staff will be reminded, weekly staff meetings and/or supervision, of their responsiblity to submit all training documents within one week of attendance. All staff are to record and assess the training on the MATER Staff Training Form and submit all completed forms, with a certificate, when possible within 7 days to their supervisor.
Person(s) repsonsible: Administrative Assistant, immediate Supervisor, and the Program Director
Timeframe for completion: within 30 days.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that all stairways, hallways, and exits from room were unobstructed.
Findings:
A physical plant inspection took place on December 11, 2008. The second exit on the third floor was obstructed, as the exit is accessible only through a locked door of another program.
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Plan of Correction
A letter has been sent to the Department of Health requesting an exception to this standard. In the interim, an agreement has been developed for the agency on the 3rd floor whose exit we would use in an emergency.
Person(s) responsible: Program Director
Timeframe for completion: within 30 days |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Findings:
Nine personnel records were reviewed on December 10, 2008. Documentation of training to perform assigned tasks during emergencies was required in three personnel records. The facility failed to provide documentation of training to perform assigned tasks during emergencies for two of three personnel records reviewed, #3 and 9.
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Plan of Correction
The orientation training form for new hires has been amended to include emergency training within 7 days. The immediate supervisor will be responsible to ensure this training is completed within the timreframe. The required training sheet will be completed by new staff and will be attached to the emergency protocol sheet. All completed sheets will be copied and filed in the staff's training folder.
Person(s) responsible: Immediate Superivsor and Administrative Assistant
Timeframe for completion: Within two (2) weeks
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill records, the facility failed to provide documentation of the use of a fire alarm or smoke detector during each fire drill.
Findings:
The fire drill records were reviewed on December 11, 2008. The facility documented the use of a verbal announcement of the fire drills from January 2008 through November 2008. The facility failed to document that this method of announcing a fire drill was approved by the Division of Drug and Alcohol Program Licensure.
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Plan of Correction
Letter of Exception has been sent to the Department of Health for approval for new location. Approval has been received.
Person(s) repsonsible: Program Director
Timeframe for completion: Immediate |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on the physical plant inspection, the facility failed to maintain protective caps over each electrical outlet in the child care area.
Findings:
The physical plant inspection was conducted on December 11, 2008. The facility failed to supply two of the electrical outlets in the child care area with protective caps.
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Plan of Correction
All outlets will be checked on a daily basis. All staff will be responsible to check outlets in the facility. Also, an on-going supply of outlet covers will be maintained by the agency for immediate replacement.
Person (s) responsible: Clinical Supervisor, Administrative Assistant, and PCC Staff.
Timeframe for completion: Immediate |
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 eight client records, the facility failed to document a psychosocial evaluation for each client.
Findings:
Eight client records were reviewed on December 11, 2008. Psychosocial evaluations were required in four client records. The facility failed to document a psychosocial evaluation in four of four client records reviewed, #1, 2, 3 and 4. The facility failed to document a clinical assessment of assets/strengths, support systems, negative factors and attitude toward treatment in #1, 3 and 4. The facility failed to document coping mechanisms in #1, 2 and 3.
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Plan of Correction
The Clinical Supervisor will complete a documented training on how to clinically capture the information on the psychosocial and assess and integrate information (assets/strengths, support systems, negative factors)into formulating a clinical evaluation, so a comprehensive treatment plan can be developed to support the assessment.The completed assessments will be monitored by the Clincial Supervisor within 30 days of admission and within weekly supervision, as needed.
Perons(s)responsible: Clinical Supervisor and Primary Counselor
Timeframe for completion: training completed on 12/17/09 |
711.92(c)(2) LICENSURE Type & Frequency of TX
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in five of five client records reviewed.
Findings:
Eight client records were reviewed on December 11, 2008. Type and frequency of treatment and rehabilitation services was required in five client records. The clients were receiving group sessions but group sessions and the frequency of these sessions was not documented on the comprehensive treatment plan.
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Plan of Correction
The Clinical Supervisor will complete a training, with the clinical staff, on identifying current clinical issues, problem list, etc., assessing for the appropriate group intervention, documenting with the patient, in the session, the groups, frequency, and purpose. The training will be documented and placed in the staff's training folder by the Administrative Assistant. The Clinical Supervisor will monitor all treatment plans for compliance on a bi-monthly basis when the treatment plans are due, or as needed. Also, any clinical documentation issues relative to groups and frequency will be addressed on a weekly basis.
Perons(s)responsible: Clinical Supervisor,, Primary Counselor, and Administrative Assistant
Timeframe for completion: Training completed on 12/17/09 |
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 the review of client records, the facility failed to document treatment plan updates in two of three client records.
Findings:
Eight client records were reviewed on December 11, 2008. Treatment plan updates were required in three client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan on the treatment plan update in client record #5. The facility did not document two treatment plan updates which were due on 2/21/08 and 4/21/08 in client record #6.
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Plan of Correction
A spreadsheet to monitor due dates for clinical documents has been designed and impelmented. The flowchart will be monitored on a monthly basis by the Clinical Supervisor. Any missing documents will be communicated to the counselor and expected to be completed by Tuesday of the following week.
The Clinical Supervisor will train all clinical staff in the integration of the client's progress or barriers to progress. This training will include reference to previous goals and how to measure if the goals are being met; need to be modified; or have been achieved. Training will occur within 30 days.
Person(s) responsible: Clinical Supervisor
Timeframe for completion: within 30 days
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711.93(b)(1)(i) LICENSURE Removal of Portions Prior to Cl Inspection
711.93. Client records.
(b) Client access to records.
(1) A client has the right to inspect his own records, subject to the following limitations:
(i) The project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.
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Observations
Based on a review of administrative documents, the facility failed to document policy that the project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client.
Findings:
Administrative documents were reviewed on December 10, 2008. The facility failed to document the policy in the manual that the project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client. The facility also did not document in policy that the reasons for removing sections shall be documented and kept on file.
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Plan of Correction
The language will be changed in the Patient's Rights to include the temporary removal of portions of the record...to achieve compliance. All patients will be given an addendum sheet to the Patient's Rights document, stating this standard, and any existing documents will be disgarded.
Person(s) responsible: Program Director, Clinical Supervisor, and Administrative Clinic Coordinator
Timeframe for completion: Within 30 days |