INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 18, 2021 through May 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on the review of patient records, the program failed to verify the individual ' s identity, including name, address, date of birth, emergency contact and other identifying data in two of twelve applicable patient records reviewed.
Patient # 6 was admitted April 23, 2021 and was discharged on May 10, 2021. There was no documentation in the patient record indicating that the patient ' s identity was verified.
Patient #10 was admitted on January 26, 2021 and was discharged on February 1, 2021. There was no documentation in the patient record indicating that the patient ' s identity was verified.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
The Admission Intake Workers were in-serviced by the CEO on 5/26/2021 that is an individual does not present a government-issued ID, they must verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data with the insurance company and document.
The Admissions Intake Workers will also continue to take a picture of those individuals.
In order to maintain future compliance, the Performance Improvement Coordinator will monitor random monthly records to assure the identity of the individual is verified and documented by the Admission Intake Worker, when they do not present with a government-issued ID. This monitoring will be conducted for the next 6 months to assure future compliance. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
|
Observations
Based on the review of patient records, the program failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in one of twelve applicable patient records.
Patient #5 was admitted on April 23, 2021 and was discharged on May 5, 2021. It was not documented in the patient record that the patient was informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
|
Plan of Correction
The current "Consent to Treatment with an Approved Narcotic Drug" form all female patients sign upon admission was revised by the Clinical Supervisor on 6/7/2021 to now include an informed statement of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment programs.
The Admissions Intake Workers were in-serviced on the newly revised form. The Admissions Intake Workers will have all female patients sign the form upon admission.
In order to assure continued compliance, the Performance Improvement Coordinator will review a random sampling of female records to assure the female patients are signed the form. The monitoring will continue for the next 6 months and the results of those studies will be reported to the Performance Improvement Committee on a quarterly basis. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on the review of patient records, the program failed to document an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in two of twelve applicable patient records reviewed.
Patient #5 was admitted on April 23, 2021 and was discharged on May 5, 2021. An informed, voluntary, written consent was not documented in the patient record.
Client #7 was admitted on April 30, 2021 and was discharged on May 12, 2021. An informed, voluntary, written consent was not documented in the patient record.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
|
Plan of Correction
Documentation of informed, voluntary, written consent before an agent is administered to the patient for either maintenance or detoxification treatment was done, however, there was a computer issue which did not allow the signature of the patient to be seen by the inspector.
The computer issue was resolved on-site by the Hospital's IT Department on 5/19/2021.
In order to assure continued compliance, the IT Officer will monitor randomly selected records on a monthly basis for the next 6 months. The results of this monitoring will be presented to the Performance Improvement Committee on a quarterly basis. |
711.61(c)(1) LICENSURE Disclosure to Client
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on the review of client records, the project failed to disclose to the client the criteria for admission, treatment, completion and discharge in seven of seven applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective 6/7/2021, an Admissions Package was developed for all patients to receive at time of admission. This Admissions Package includes the following: Criteria for Admission, Treatment, Completion and Discharge & Fee Schedule.
The Admissions Intake Workers were in-serviced by the CEO to distribute the Admissions Package to all patients being admitted to Kensington Hospital. The Admissions Intake Workers will have the patient sign for the Admissions Package and place that on the medical record.
In order to assure continued compliance, the Performance Improvement Coordinator will monitor monthly charts to assure all patients are signing for receipt of the Admissions Package. The duration of this monitoring will be for 6 months. The results of the monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
711.61(c)(2)(iii) LICENSURE Fee Schedule
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with:
(iii) Fee schedule.
|
Observations
Based on the review of client records, the project failed to ensure that client orientation to the project included the fee schedule in seven of seven applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective 6/7/2021, an Admissions Package was developed for all patients to receive at time of admission. This Admissions Package includes the following: Criteria for Admission, Treatment Completion & Discharge & Fee Schedule.
The Admissions Intake Workers were in-serviced by the CEO on 6/7/2021 to distribute the Admissions Package to all patients being admitted to Kensington Hospital. The Admissions Intake Workers will have the patient sign for the Admissions Package and place that on the medical record.
In order to assure continued compliance, the Performance Improvement Coordinator will monitor monthly charts to assure all patients are signing for receipt of the Admissions Package . The duration of this monitoring will be for 6 months and the results of the monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
711.51(b)(1) LICENSURE Disclosure to Client
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on the review of client records, the project failed to disclose to the client the criteria for admission, treatment, completion and discharge in seven of seven applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective 6/7/2021, an Admissions Package was developed for all patients to receive at time of admission. This Admissions Package includes the following: Criteria for Admission, Treatment, Completion and Discharge and Fee Schedule .
The Admissions Intake Workers were in-serviced by the CEO on 6/7/2021 to distribute the Admissions Package to all patients being admitted to Kensington Hospital. The Admissions Intake Workers will have the patient sign for the Admissions Package and place that on the medical record.
In order to assure continued compliance, the Performance Improvement Coordinator will monitor monthly charges to assure all patients are signing for receipt of the Admissions Package. The duration of this monitoring will be for 6 months and the results of the monitoring will be reported to the Performance Improvement Committee quarterly. |
711.51(b)(2)(iii) LICENSURE Orientation- Fee Schedule
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but is not limited to, a familiarization with:
(iii) Fee schedule.
|
Observations
Based on the review of client records, the project failed to ensure that client orientation to the project included the fee schedule in seven of seven applicable client records reviewed.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective 6/7/2021, an Admissions Package was developed for all patients to receive at time of admission. This Admissions Package includes the following: Criteria for Admission, Treatment, Completion & Discharge, and Fee Schedule.
The Admissions Intake Workers were in-serviced by the CEO on 6/7/2021 to distribute the Admissions Package to all patients being admitted to Kensington Hospital. The Admissions Intake Workers will have the patient sign for the Admissions Package and place that on the medical record.
In order to assure continued compliance the Performance Improvement Coordinator will monitor monthly charts to assure all patients are signed for receipt of the Admissions Package. The duration of the monitoring will be for a 6 month period and the results of the monitoring will be reported to the Performance Improvement Committee quarterly.
|
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. 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:
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven applicable client records reviewed.
Client #5 was admitted on April 23, 2021 and was discharged on May 5, 2021. There was not a valid release of information form for the funding source documented in the client record.
Client #7 was admitted on April 30, 2021 and was discharged on May 12, 2021. There was not a valid release of information form for the funding source documented in the client record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The Counselors were re-inserviced on 6/7/2021 by the Clinical Supervisor to obtain an informed & voluntary consent from the patient for the Disclosure of Information contained in the client record.
In order to assure continued compliance, the Performance Improvement Coordinator will now review monthly random charts to assure an informed & voluntary consent is obtain from every patient.
The monitoring will be for 6 months and the results will be reviewed and reported to the Performance Improvement Committee on a quarterly basis.
|