INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19-20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 fire drill log, the facility failed to document the exit route used during fire drills and to alternate exits during drills.
The findings include the following:
The facility failed to document the exit route used during fire drills.
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Plan of Correction
A meeting was held with the Hospital's Fire Safety Officer on 11/13/17 to discuss the corrective action plan on this deficiency.
The Fire Safety Officer was requested to document the fire drills to include the amount of time to reach the exit tower door and the exit that would be used in the event that an evacuation was required. The Fire Safety Officer will also document the amount of time to travel form one smoke compartment to the other including the time to reach the exit tower as well as alternating the smoke compartments and exit towers used for the drills. This Fire Drill documentation will be conducted one per shift per quarter.
The Facilities Director is ultimately responsible to assure monthly fire drills are conducted and properly documented and maintained on file. The Facilities Director will review the fire drill documentation each month to assure continued compliance. The results of his findings will be reported to the Safety Committee/Patient Safety Committee each month. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on a review of nine non-hospital short-term hosptial detox client records on September 19-20, 2017, the facility failed to verify the client's identity prior to the administration of an agent in client records, #4, 5 and 7.
Client #4 was admitted on September 14, 2017. Client #4's first dose was September 14, 2017.
Client #5 was admitted on September 15, 2017. Client #5's first dose was September 16, 2017.
Client #7 was admitted on April 11, 2017 and discharged on April 16, 2017. Client #7's first dose was April 12, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Since client #4 was discharged on 9/19/17, Client #5 was discharged on 9/20/17 and Client #7 was discharged on 4/16/17, Kensington Hospital was unable to obtain a proper ID from the clients;
However, effective 10/11/17, Kensington Hospital ceased accepting any individuals seeking Drug & Alcohol Treatment services that does not have the proper identification such as:
- any federal, state, or local issued photo identification card or clean and legible copy (expired is acceptable),
- Passports;
- Student photo identification card which contains the date of birth;
- Photo identification cards issued by a narcotic treatment program or clear and legible copy;
- Unaltered check cashing photo identification card;
- Veteran Health Identification card.
If a patient does not have a photo identification, a social security card and one of the following can be accepted:
- Birth Certificate;
- Certificate of U.S. Citizenship or Consular Report or Birth Abroad (DOS Form FS-240);
- Certificate of Naturalization (USCIS Form N-550 or N-570.
In order to assure the corrective action is implemented and to assure continued compliance, the Clinical Supervisor has been assigned the responsibility to conduct weekly random chart reviews to monitor continued compliance. These results will be forwarded to the Performance Improvement Committee for the next two months to assure continued compliance.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's unusual incidents, the facility failed to notify the Department with the required 48 hours.
The unusual incident form documented on 9/12/17 stated that the client was verbally and physically abusive to patients and staff.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 10/16/17, the Chief Nursing Officer has been assigned the responsibility of reporting all Unusual Incidents to the Department within 48 hours of the Unusual Incident. A copy of the Unusual Incident Report and the confirmation of submission to the Department will be maintained with the Patient Safety Officer.
The Employee Educator provided in-service training to the Non-Hospital Nursing Staff, including the Chief Nursing Office, as well as, the Counseling Staff on the proper and timely reporting of Unusual Incident Reports to the Department within 48 hours following the unusual event. The initial in-service was held on 10/16/17 and will be completed by 10/24/17.
The Chief Nursing Officer will assure continued compliance by immediately following up on any Unusual Incidents that are late in reporting.
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711.61(c)(4) LICENSURE Consent to Treatment
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment in one of nine records reviewed, #2.
Client #2 was admitted on August 17, 2017.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Since Client #2 was discharged on 9/21/17, a consent for treatment was unable to be signed.
The Vice President of Patient Affairs held a meeting with the Hospital's Admission Intake Staff on 10/11/17 to discuss the issue of obtaining a Consent to Treatment on every patient being admitted to Kensington Hospital.
The Performance Improvement Coordinator will then conduct monthly random chart reviews to assure continued compliance in this area. Results of these reviews will be presented to the Performance Improvement Committee for the next six (6) months to assure compliance.
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711.61(c)(6) LICENSURE Psychosocial Evaluation
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of nine client records, the facility documented a psychosocial evaluation which did not include an evaluation of the client. The psychosocial evaluation only documented what the client stated.
Client #1 was admitted on September 15, 2017. The psychosocial evaluation was documented on September 19, 2017
Client #2 was admitted on September 17, 2017. The psychosocial evaluation was documented on September 17, 2017.
Client #3 was admitted on September 14, 2017. The psychosocial evaluation was documented on September 14, 2017.
Client #4 was admitted on September 14, 2017. The psychosocial evaluation was documented on September 15, 2017.
Client #5 was admitted on September 15, 2017. The psychosocial evaluation was documented on September 18, 2017.
Client #6 was admitted on April 8, 2017 and discharged on April 13, 2017. The psychosocial evaluation was documented on April 11, 2017.
Client #7 was admitted on April 11, 2017 and discharged on April 16, 2017. The psychosocial evaluation was documented on April 13, 2017.
Client #8 was admitted on May 7, 2017 and discharged on May 12, 2017. The psychosocial evaluation was documented on May 9, 2017.
Client #9 was admitted on June 10, 2017 and discharged on June 15, 2017. The psychosocial evaluation was documented on June 13, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Vice President of Patient Affairs held a meeting on 10/11/17 with the Hospital's Admission Intake Staff on documenting a proper and thorough Psychosocial evaluation at the time of admission.
The Performance Improvement Coordinator will then conduct monthly random chart reviews to assure continued compliance in this area. Results of these reviews will be presented to the Performance Improvement Committee for the next six (6) months to assure compliance.
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711.62(a) LICENSURE Complete Client Record
711.62. 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 contained in 115.32 (relating to contents), the client record shall include the following:
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Observations
Based on a review of client records on September 19-20, 2017, the facility failed to document a complete client record in all records reviewed. The drug and alcohol support plan and the client ' s record of service were not documented as of the date of the licensing inspection
Client #1 was admitted on September 15, 2017.
Client #2 was admitted on September 17, 2017.
Client #3 was admitted on September 14, 2017. Additionally, the counselor failed to have signed progress notes dated September 19, 2017 and September 18, 2017.
Client #4 was admitted on September 14, 2017. Additionally, the counselor failed to have signed progress notes dated September 15, 2017 and September 19, 2017
Client #5 was admitted on September 15, 2017.
Client #6 was admitted on April 8, 2017 and discharged on April 13, 2017. Additionally, an aftercare plan was not documented and the counselor failed to have signed a progress note dated April 11, 2017.
Client #7 was admitted on April 11, 2017 and discharged on April 16, 2017. Additionally, the counselor failed to have signed progress notes dated September 13, 2017 and September 14, 2017
Client #8 was admitted on May 7, 2017 and discharged on May 12, 2017. Additionally, a follow-up was not documented.
Client #9 was admitted on June 10, 2017 and discharged on June 15, 2017. Additionally, a discharge summary and follow-up was not documented and the counselor failed to have signed progress notes dated June 13, 2017 and June 14, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will in-service the Counselors to complete and document the following on the all patients:
- The Drug & Alcohol Support Plan;
- The client's Record of Service;
- Aftercare Plan;
- Discharge Summary;
- Follow Up;
- Signing and dating of all Progress notes;
The in-service training will be completed by 10/26/17.
In order to assure continued compliance, the Clinical Supervisor will conduct random monthly chart reviews to evaluate the compliance of the above-mentioned issues. The results of these studies will be presented to the Performance Improvement Committee for the next six (6) to assure continued compliance.
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711.62(c)(2) LICENSURE Informed & Voluntary Consent
711.62. 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:
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Observations
Based on a review of nine client records on September 19-20, 2017, the facility failed to ensure the client's confidentiality in records, 3, 4, 5, 7, 8 and 9.
Client #3 was admitted on September 14, 2017. The counselor documented on a progress note dated September 19, 2017, that a call was made by the counselor to a treatment provider about the client, but no consent to release on file for this treatment provider.
Client #4 was admitted on September 14, 2017. The counselor documented on a progress note dated September 19, 2017, that a call was made by the counselor to an agency about the client, but no consent to release on file for this agency.
Client #5 was admitted on September 15, 2017. A consent to release to the client's funding source dated September 15, 2017 did not have the client and counselor's signature.
Client #7 was admitted on April 11, 2017 and discharged on April 16, 2017. The counselor documented on a progress note dated April 13, 2017, that a call was made by the counselor to an agency about the client, but no consent to release on file for this agency.
Client #8 was admitted on May 7, 2017 and discharged on May 12, 2017. A consent to release to the client's funding source dated May 7, 2017 did not have the client and counselor's signature.
Client #9 was admitted on June 10, 2017 and discharged on June 15, 2017. A consent to release to the client's funding source dated June 16, 2017 did not have the staff and counselor's signature. Additionally, a call was made to the court system on June 13, 2017, that a call was made by the counselor to an agency about the client, but no consent to release on file for the court system.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Since the following clients were discharged as follows:
Client #3 on 9/19/17,
Client #4 on 9/19/17,
Client #5 on 9/20/17,
Client #7 on 4/16/17,
Client #8 on 5/12/17,
Client #9 on 6/15/17, the Hospital was unable to obtain a signed and dated consent to release form from these clients.
The Executive Assistant will revise the Consent for Release (Disclosure of Information) form to include all the customary funding sources, courts and treatment providers in order to allow the counselor to easily check off the agency/organization they are obtaining the client's consent for. Only one (1) form will be utilized for all agencies/organizations. All Consents for Release are signed by the counselor and patient concurrently. The form will be available for use by the Counselor by 10/27/17.
The Clinical Supervisor will also provide in-service training to the Counselors by 10/26/17 on assuring the Consent for Release form is completed properly and thoroughly, as well as, signed by both the Counselor and the patient.
In order to assure continued compliance regarding this issue, the Performance Improvement Coordinator will conduct monthly random chart reviews to assure the revised Consent for Release forms are thoroughly completed and signed by both the counselor and patient. These results will be submitted to the Performance Improvement Committee for the next six (6) months to assure continued compliance. |
710.21(b)(4) LICENSURE Admission - Detoxification
§ 710.21. Admission-detoxification.
(b) Admission procedures shall include documentation of the following:
(4) Psychosocial evaluation.
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Observations
Based on the review of two client records, the facility failed to document a psychosocial evaluation during intake.
Client #1 was admitted on August 1, 2017 and discharged on August 4, 2017.
Client #2 was admitted on August 28, 2017 and discharged on September 2, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Vice President of Patient Affairs met with the Hospital's Admission Intake Staff on 10/11/17 to discuss completing a Psychosocial Evaluation on all patients being admitted to Kensington Hospital at the time of admission.
The Clinical Supervisor will conduct monthly random chart reviews to assure continued compliance in this area. Results of these reviews will be presented to the Performance Improvement Committee for the next six (6) months to assure compliance.
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710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on the review of two client records, the facility failed to document a follow-up during intake.
Client #1 was admitted on August 1, 2017 and discharged on August 4, 2017.
Client #2 was admitted on August 28, 2017 and discharged on September 2, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #1 discharged on 8/4/17, therefore follow up should have been done on 8/11/17 (7 days after discharge).
The Counselor documented a follow up on this Client on 11/22/17.
Client #2 discharged on 9/2/17, therefore follow up should have been done on 9/9/17 (7 days after discharge).
The Counselor documented a follow up on this Client on 11/22/17.
The Clinical Supervisor in-serviced the Counselors on 10/26/17 to complete and document the following on all patients:
The drug & Alcohol Support plan;
The client's Record of Service;
Follow up on the client within 7 days of discharge.
The Hospital hired a Performance Improvement Coordinator effective 11/6/17 who will be responsible to conduct follow up on each discharged patient.
In order to assure continued compliance, the Clinical Supervisor will conduct random monthly chart reviews to evaluate the compliance of the above-mentioned issues. The results of the studies will be presented to the Performance Improvement Committee for the next six (6) months to assure future compliance. |
710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of 2 client records on September 20, 2017, the facility failed to ensure the client's confidentiality in record #2.
Client #2 was admitted on August 28, 2017 and discharged on September 2, 2017. A consent to release for the client's funding source, dated September 28, 2017, failed to have the client and staff signatures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #2 was discharged 9/2/17, therefore, the Hospital is unable to obtain a signed and dated consent to release form for the client's funding source.
The Vice President of Patient Affairs will in-service the admissions intake staff on obtaining signatures from clients for all consent to release forms upon intake on all in-coming patients.
The in-service training will be completed by 10/27/17.
In order to assure continued compliance, the Clinical Supervisor will conduct random monthly chart reviews to evaluate the compliance of the above-mentioned issues. The results of these studies will be presented to the Performance Improvement Committee for the next six (6) to assure continued compliance.
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