INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on February 15, 2018, by staff from the Division of Drug and Alcohol. Based on the findings related specifically to the complaint investigation, the allegations made against Kensington Hospital Outpatient Treatment Program were unable to be substantiated. However, based on other findings during this investigation, the facility was found out of 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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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 the results of a complaint investigation conducted on February 15, 2018, regarding allegations of client against client violence, it was determined that the facility failed to file a written Unusual Incident report to the Department within 48 hours.Unusual incident date - January 4, 2018 client against client violence. This information was reviewed with facility staff.
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Plan of Correction
All appropriate staff will be notified of any Unusual events. Staff person(s) evidencing the unusual incident will complete a Kensington Hospital internal incident report. The Program Director will also follow up with persons involved in the incident, including the staff involved.
The Program Director will also re-educate all Program Staff through Supervision meetings by Wednesday, 3/7/18. Staff will be re-educated that all unusual incidents must be reported to DDAP within 48 hours of the incident.
The Vice President of Patient Affairs will also re-educate the Security staff via one-to-one meetings by Wednesday, 3/7/18. Security staff will be re-educated that all unusual incidents must be reported to DDAP within 48 hours of the incident. |