INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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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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 a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of five applicable client records reviewed.
Client # 1 was admitted on April 3, 2025 and was still active at the time of the inspection. A treatment plan update was completed on June 16, 2025 and the next update was due no later than August 16, 2025; however, the update was completed on September 4, 2025.
Client # 3 was admitted on May 14, 2025 and was still active at the time of the inspection. A treatment plan update was completed on August 18, 2025 and the next update was due no later than October 18, 2025; however, the update was completed on October 30, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/29/2025 for failure to review and update treatment and rehabilitation plans at least every 60 days per 711.92(d) Tx Plan Update L 0969 711.92. In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/30/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures. All counselors were reminded to routinely monitor the "My Treatment Plans" widget on their EHR dashboards for upcoming and overdue treatment plan due dates. Clinical supervisors increased oversight of treatment plan compliance and reinforced the importance of timely completion during individual supervision. Additionally, treatment plan reviews and update requirements were addressed in group supervision with all counseling staff.
Client #1 currently has a treatment plan in compliance, and the due date is 1/30/2026.
Client #3 currently has a treatment plan in compliance, and the due date is 2/27/2026.
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711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to include the specific information to be disclosed on consent to release information forms in one of seven client records reviewed.
Client # 1 was admitted on April 3, 2025 and was still active at the time of the inspection. There was a release of information form to multiple parties that included funding sources, a transportation company, a laboratory, and other treatment providers, signed by the client on April 10, 2025; however, the specific information to be disclosed was not documented on the release form.
This is a repeat citation from the November 15, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A citation was issued on 12/29/2025 for failure to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client's record: The specific information disclosed, per 711.93(c)(2)(ii) Specific Info. Disclosed L 1003 711.932. In response, the Thomas Jefferson University (TJU) NARP program developed and implemented a Plan of Correction to address the deficiency and prevent recurrence.
On 12/30/2025, the TJU NARP Executive Director and Clinical Supervisor implemented corrective measures and conducted a review of all patient charts within Outreach. This patient chart was the only chart identified with an incorrect Combined Release of Information (ROI), as the intake had been completed on paper rather than in the EHR at the time of admission.
All patient intakes are conducted exclusively within the EHR, which contains updated and compliant releases and consents.
All intake documentation is reviewed and will continue to be reviewed by a clinical supervisor.
The facility has provided updated paper intake documentation to the Outreach counselor for use in the event that a future intake must be completed outside of the EHR. Current paper and EHR Combined ROI's have been updated to include the following:
The information released to the above entities is requested by the patient for the purposes of treatment, care coordination, payment, transportation, and/or health care operations.
Client #1 is scheduled to complete updated ROIs on 1/8/2026. |