INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12-14, 2010 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 and a plan of correction is due on February 16, 2010.
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Plan of Correction
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711.14(b)(5) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to notify the Department within 90 days of the occurrence of the change in the authorized maximum client capacity.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on January 12-14, 2010. The facility ' s authorized maximum capacity for Outpatient Maintenance clients is 360. The Staffing Requirements Facility Summary Report, signed by the facility director, indicated the number of Outpatient Maintenance clients as 373.
The facility director signed the Staffing Requirements Facility Summary Report on January 10, 2010 to attest to the accuracy, veracity, and authenticity of the stated information.
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Plan of Correction
The census will be reduced to current capacity via discharge of clients not actively participating in treatment. Going forward, closer attention to admissions and discharges will ensure that cap is not exceeded in the future. It will be the responsibility of the Program Coordinator and Facility Director to oversee this. Whether the capacity increase is or is not granted, the proposed oversight will ensure future compliance. |
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 the review of client records, the facility failed to document a psychosocial evaluation within 30 days after the point of admission in accordance with their policy and procedures in three of eight client records.
The findings include:
Eight client records were reviewed on January 13-14, 2010. All eight records required documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation in client records # 1, 4 and 7.
The facility ' s policy titled " Biopsychosocial Evaluation " states:
" ...Within the next 30 days [after point of admission] the patient and his/her assigned counselor should meet for individual counseling sessions where the biopsychosocial evaluation is completed and provides a basis for the development of the Comprehensive Treatment Plan. "
The facility did not document a biopsychosocial evaluation within 30 days of admission as stated in their policy manual in client records # 1, 4 and 7.
The admission date for client # 1 was 10/13/09, and the discharge date for client # 1 was 12/7/09, but a biopsychosocial evaluation was documented at the time of review on 1/14/09.
The admission date for client # 4 was 8/7/09, but the biopsychosocial evaluation was not documented at the time of review on 1/14/09.
The admission date for client # 7 was 7/9/09, but the biopsychosocial evaluation was documented on 8/25/09.
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Plan of Correction
Newly implemented chart review procedures were established the week of February 1. The charts of all newly admitted clients will be reviewed by supervisory staff 30 days following admission to ensure compliance with this standard. The Facility Director will monitor supervisory activity to ensure chart compliance reviews occur on a monthly basis. |
711.94(b) LICENSURE Display Hours of Operation
711.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based upon observation during the physical plant tour conducted on January 13, 2010 and an interview with the facility director, the facility failed to display the hours of operation to the general public.
The findings include:
A tour of the facility ' s physical plant was conducted on January 13, 2010 at approximately 12:30 PM. The hours of project operation were not posted for the general public. The facility director confirmed that the hours of operation were not posted.
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Plan of Correction
The hours of operation were posted on the door on January 15, 2010. Routine inspection to be conducted by the Facility Director and/or Program Coordinator will ensure that the hours remain posted on the front door. |
711.94(c) LICENSURE Display Emerg. Telephone Number
711.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based upon observation during the physical plant tour conducted on January 13, 2010 and an interview with the facility director, the facility failed to display a telephone number to the general public for emergency purposes.
The findings include:
A tour of the facility ' s physical plant was conducted on January 13, 2010 at approximately 12:30 PM. An emergency telephone number was not posted for the general public. The facility director confirmed that a telephone number was not posted.
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Plan of Correction
A phone number to be used by the general public was posted on the door on January 15, 2010. Routine environment of care inpecections conducted by the facility Director and/or Program Coordiantor will ensure the continued posting of this information. |