INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on September 26, 2023 through September 27, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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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.
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Observations
Based on a review of patient records, the facility failed to obtain and informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in two of twenty-six patient records reviewed.
Patient #6 was admitted to the inpatient non-hospital detoxification activity on July 13, 2023 and was discharged on July 18, 2023. The physician first prescribed maintenance medication to the patient on July 13, 2023. There was no consent to treat with an agent documented in the patient record prior to the first dose.
Patient #12 was admitted to the inpatient non-hospital activity on July 18, 2023 and was discharged on July 25, 2023. The physician first prescribed maintenance medication to the patient on July 13, 2023. There was no consent to treat with an agent documented in the patient record prior to the first dose.
This is a repeat citation from the October 5, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services in-serviced the inpatient Counseling staff on the Consent Policy & Procedure on 10/16/2023.
Patients must sign an informed, voluntary, written consent before a narcotic agent is administered to the patient for maintenance or detoxification treatment.
In order to assure continue compliance, the Director of Behavioral Health Services will conduct monthly chart reviews to assure patients are signing an informed, voluntary, written consent before a narcotic agent is administered for maintenance or detoxification treatment. The results from this monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document the completion of an initial drug-screening analysis for each prospective patient in two of twenty-six patient records reviewed.
Patient #27 was admitted to the inpatient hospital activity on December 24, 2022 and was discharged on December 25, 2022. The physician first prescribed maintenance medication to the patient on December 24, 2022. There was no initial urinalysis drug-screen documented in the patient record prior to the first dose.
Patient #28 was admitted to the inpatient hospital activity December 16, 2022 and was discharged on December 24, 2022. The physician first prescribed maintenance medication to the patient on December 16, 2022. There was no initial urinalysis drug-screen documented in the patient record prior to the first dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health provided an educational in-service to the Admissions Intake Staff and the inpatient Counseling staff that there must be an initial urinalysis drug-screen done and documented in the medical record.
In order to assure future compliance, the Director of Behavioral Health Services will conduct monthly chart reviews to assure all patients admitted to Kensington Hospital's inpatient Behavioral Health Services Unit must have an initial urinalysis drug-screen done and documented on the medical record. The results from this monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, a narcotic treatment physician failed to determine the proper dose level for the initial dose of the patient in three of twenty-six patient records reviewed.
Patient #5 was admitted to the inpatient non-hospital detoxification activity on December 20, 2022 and was discharged on December 24, 2022. The initial dose level of the patient was determined by the certified registered nurse practitioner on December 20, 2022 and not the narcotic treatment physician.
Patient #13 was admitted to the inpatient non-hospital activity on May 23, 2023 and was discharged on June 27, 2023. The initial dose level of the patient was determined by the certified registered nurse practitioner on May 24, 2023 and not the narcotic treatment physician.
Patient #23 was admitted to the inpatient hospital activity on June 22, 2023 and was discharged on June 27, 2023. The initial dose level of the patient was determined by the certified registered nurse practitioner on June 23, 2023 and not the narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/16/2023 and 10/17/2023, the Medical Director in-serviced the Medical Staff to the fact the initial dosage of methadone for patients must be determined and written by a Physician and not a Certified Registered Nurse Practitioner (CRNP).
In order to assure future compliance, the Performance Improvement Coordinator, will conduct monthly chart reviews to assure all initial dose of methadone is determined and written by a physician.
The results from the monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient in one of one applicable patient records reviewed.
Patient #20 was admitted to the inpatient hospital detoxification activity on January 13, 2023 and was transferred out on January 19, 2023. The patient record did not document that the receiving narcotic treatment program was notified of the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/17/2023, the Director of Behavioral Health Services in-serviced the inpatient Counseling staff that when a patient is transferred from Kensington Hospital to another facility, the patient transfer file must include the following information: admission date, medical & psychosocial summaries, dosage level, urinalysis reports/summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
In order to assure future compliance, the Director of Behavioral Health Services will conduct monthly chart reviewed on patients transferred from Kensington Hospital to assure the following documentation was provided in the patient transfer file: admission date, medical & psychosocial summaries, dosage level, urinalysis reports/summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
The results of the monthly chart reviews will be forwarded to the Performance Improvement Committee on a quarterly basis. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in five of five applicable patient records reviewed.
Patient #14 was admitted to the inpatient non-hospital activity on June 12, 2023 and was discharged on June 30, 2023. The patient record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #15 was admitted to the inpatient hospital detoxification activity on June 21, 2023 and was discharged on June 24, 2023. The patient record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #16 was admitted to the inpatient hospital detoxification activity on December 21, 2022 and was discharged on December 23, 2022. The patient record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #20 was admitted to the inpatient hospital detoxification activity on January 13, 2023 and was discharged on January 19, 2023. The patient record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #23 was admitted to the inpatient hospital activity on June 22, 2023 and was discharged on June 27, 2023. The patient record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/17/2023, the Director of Behavioral Health Services conducted an in-service training to the inpatient Counseling staff that they must document in the medical record that they notified the transferring narcotic treatment program of the patient's admission date and the date of the patient's initial dosage of methadone given.
In order to assure continued compliance, the Director of Behavioral Health Services will conduct chart review on a monthly basis to assure counselors are documenting in the medical record the patient's admission date and the patient's initial dosage of methadone to the transferring narcotic treatment program.
The Director of Behavioral Health Services will forward the results from the monthly monitoring to the Performance Improvement Committee on a quarterly basis.
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711.62(c)(3) LICENSURE Client's copy of consent
711.62. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in one of seven client records reviewed.
Client #7 was admitted to the inpatient non-hospital detoxification activity on July 3, 2023 and was discharged on July 5, 2023. A release of information form to an emergency contact was signed and dated by the client on July 3, 2023; however, the form did not indicate that a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/13/2023, the Director of Behavioral Health Services provided an in-service training to the inpatient counseling staff on the following:
1) A copy of the patient's consent must be offered to the patient and it must be documented in the medical record;
2) A Release of Information form for emergency contact must also be offered to the patient and documented in the chart.
In order to assure continued compliance, the Director of Behavioral Health Services will perform monthly chart reviews to assure that:
1) A copy of the patient's consent is offered to the patient and documented in the medical record;
2) A Release of Information form for emergency contact is offered to the patient and documented in the chart.
The results of this monthly monitoring will be reported to the Performance Improvement Committee for at least six (6) months.
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711.52(a)(3) LICENSURE Mngt of Tx Services- Written Procedures
711.52. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services, which shall include, but not be limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of patient records, the facility failed to follow the written client follow-up policy in one of one applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client #11 was admitted to the inpatient non-hospital activity on December 24, 2022 and was discharged against medical advice on December 26, 2022; however, there was no documentation that the emergency contact was notified of the client's discharge as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/16/2023, the Director of Behavioral Health Services provided educational training to the inpatient Counseling staff on the Follow Up Policy & Procedure. Counselors were instructed that the emergency contact must be notified after a patient is discharged from Kensington Hospital against medical advice.
In order to assure continued compliance, the Director of Behavioral Health Services will conduct monthly chart reviews to assure the emergency contact is contacted after a patient is discharged against medical advice.
The results from the monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis for at least six (6) months.
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711.53(c)(2)(iv) LICENSURE Dated Signature of Client/guardian
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:
(iv) The dated signature of client or guardian.
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Observations
Based on a review of client records, the facility failed to document dated signature of client or guardian for under 42 CFR2.14(a) and (b) and 2.15 (relating to minor parents; and incompetent and deceased patients) on release of information forms in one of seven client records reviewed.
Client #13 was admitted to the inpatient non-hospital activity on May 23, 2023 and was discharged on June 27, 2023. There was a release of information form to a recovery house that was signed and dated by the client on May 24, 2023; however, the dated signature of the client was not documented.
This is a repeat citation from the October 5, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/16/2023, the Director of Behavioral Health Services provided in-service training to the inpatient Counseling staff on the Release of Information requirements. There must be a dated signature of the patient on the Release of Information form and it must be documented in the medical record.
In order to assure continued compliance, the Director of Behavioral Health Services will conduct monthly chart reviews to assure the Release of Information is signed and dated by the patient and it is documented in the medical record.
The results of the monthly chart reviews will be forwarded to the Performance Improvement Committee by the Director of Behavioral Health Services to the Performance Improvement Committee on a quarterly basis for at least six (6) months. |
711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in two of seven client records reviewed.
Client #3 was admitted to the inpatient non-hospital detoxification activity on November 11, 2022 and was discharged on November 16, 2022. A release of information form to an emergency contact was signed and dated by the client on November 11, 2022; however, the form did not indicate that a copy was offered to the client.
Client #13 was admitted to the inpatient non-hospital activity on May 23, 2023 and was discharged on June 27, 2023. A release of information form to the funding source was signed and dated by the client on May 23, 2023; however, the form did not indicate that a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/16/2023, the Director of Behavioral Health Services in-serviced the inpatient counseling staff that a copy of the patient' consent must be offered to the patient and it must also be documented in the medical record.
In order for continued compliance, monthly chart reviews will be performed by the Director of Behavioral Health Services to assure the patients' consent is offered to the patient and it is documented in the medical record.
The results will be forwarded to the Performance Improvement Committee on a quarterly basis for at least six (6) months. |