INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21-22, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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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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 thirteen client records on September 21-22, 2017, the facility failed to document monthly urinalysis in client records, #1, 3, 4 and 8.Client #1 was admitted on February 3, 2012 and discharged on January 30, 2017. The facility failed to document a urinalysis report for the month of December 2016.Client #3 was admitted on May 16, 2014 and discharged on June 27, 2017. The facility failed to document a urinalysis report for the month of April 2017.Client #4 was admitted on May 14, 2014 and discharged on May 23, 2017. The last urinalysis was documented on February 21, 2017.Client #8 was admitted on April 27, 2017. The facility failed to document a urinalysis report for the month of May 2017.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor met with the Program Assistant on 10/20/17 to discuss the new procedure of placing clients on medication hold through the Methasoft EMR system twice a month to assure a UDS is obtained.
For continued compliance, the Program Assistant will also review the UDS's while checking in the clients to assure continued compliance.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of thirteen client records on September 21-22, 2017 the facility failed to ensure that the client will receive at least 2.5 hours psychotherapy services, which includes 1 hour of individual sessions in client records, #2 and 8.Client #2 was admitted on July 20, 2015 and discharged February 15, 2017. The client was only seen for individual sessions at 1 hour each during the following months; September 22, 2016, October 17 and 28, 2016 and December 2 and 15, 2016.Client #8 was admitted on April 27, 2017. The only individual session documented for the month of May 2017 was document for only 30 minutes. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor has scheduled an educational meeting with the counselors on monthly requirements of psychotherapy services during group supervision which is scheduled for 10/26/17.
In order to assure future compliance, the Clinical Supervisor will review the monthly units with each counselor during their individual supervision with her.
Also, if needed, clients will be placed on medication hold, to prevent from non-compliance with psychotherapy services. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of 5 client records on September 21-22, 2017, the facility failed to document a annual physical examination in client records, #2, 3 and 4. Client #2 was admitted on July 20, 2015 and discharged February 15, 2017. Client #3 was admitted on May 16, 2014 and discharged on June 27, 2017. The last physical was documented on May 18, 2016.Client #4 was admitted on May 14, 2014 and discharged on May 23, 2017. The last physical was documented on May 17, 2016.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor met with the Administrative Assistant on 10/19/17 to discuss this deficiency.
The Administrative Assistant will schedule clients same day or day before the annual evaluation date. Clients will be informed of the medical appointment at least one week before and given an appointment card.
Administrative Assistant will utilize the Methadosoft EMR system and include the counselor and physician on the scheduler to ensure client attends the scheduled physical examination. All clients will be placed on medication hold the day of physical examination. Administrative Assistant will be responsible for future compliance.
The Clinical Supervisor will conduct monthly random chart reviews and report those results to the Performance Improvement Committee for the next six (6) months to assure continued compliance. |
715.23(b)(21) LICENSURE Patient records
(b) Each patient file shall include the following information:
(21) Annual evaluation by the counselor.
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Observations
Based on a review of 5 client records on September 21-22, 2017, the facility failed to document a annual evaluation in client records, #2, 3 and 4. Client #2 was admitted on July 20, 2015 and discharged February 15, 2017. Client #3 was admitted on May 16, 2014 and discharged on June 27, 2017. The last annual evaluation was documented on May 18, 2016.Client #4 was admitted on May 14, 2014 and discharged on May 23, 2017. The last annual evaluation was documented on May 13, 2016.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor met with all counselors on 10/19/17 and instructed them to complete annual evaluations that need to be corrected immediately.
The Counselors will review their caseload in the beginning and the end of the month to ensure all annual evaluations are complete.
Counselors were instructed to set up reminders in the Methasoft EMR system via scheduler to ensure annual evaluations are completed within the required timeframe. The Clinical Supervisor will monitor completion of annual papperwork for clients by conducted a random chart review with results being forwarded to the Performance Improvement Committee for the next six (6) months to ensure continued compliance. |
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 March 15, 2017 stated that there was a medication error. The unusual incident form documented on May 5, 2017 stated that an unknown man (not a client) entered the building and would not leave, 911 was called.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 Officer, 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. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of eight client records that was reviewed for psychosocial evaluations, the facility failed to document a psychosocial evaluation during intake in three of those client records. Client #5 was admitted on June 29, 2017 and discharged on July 28, 2017. The psychosocial evaluation documented on August 8, 2017, wasn't documented until after the client's discharge date.Client #7 was admitted on May 30, 2017. The psychosocial evaluation wasn't documented until August 2, 2017. Client #9 was admitted on February 23, 2017. The psychosocial evaluation wasn't documented until April 19, 2017The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Superviswor met with the staff on 10/19/17 and the following was instituted:
The Administrative Assistant will inform the counselors of all new patient assignments upon the first day of admission to the Program.
The Counselors will meet with new patients within 72 hours of admission to begin biopsychosocial history and complete it within 7 days of admission.
The Counselors will then complete the biopsychosocial assessment within 30 days of admission. Counselors were instructed to set reminderes in the Methasoft EMR system via scheduler to remind them of biopsychosocial assessments and biopscyhosocial history deadlines.
The Clinical Supervisor will conduct monthly random charts reviews to assure continued compliance. The results of these chart reviews will be sent to the Performance Improvement Committee for the next six (6) months to assure continued compliance. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of thirteen client records on September 21-22, 2017, the facility failed to document one comprehensive treatment plan and another comprehensive treatment plan was documented late.Client #6 was admitted on July 8, 2017 and discharged on August 23, 2017. The facility failed to document a comprehensive treatment plan during intake.Client #8 was admitted on April 27, 2017. The preliminary treatment plan was documented on April 27, 2017 and the comprehensive treatment plan was not documented until June 27, 2017.The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
A Clinical Supervisor met with the staff on 10/19/17 and instructed Counselors to collaborate with the clients to complete comprehensive treatment plans at least one week prior to the deadline Counselors will place clients on medication hold the week of the comprehensive treatment plan due date, if needed.
The Clinical Supervisor will conduct monthly random chart reviews to ensure continued compliance. The results of the chart reviews will be reported to the Performance Improvement Committee for the next six (6) months. |
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 thirteen client records on September 21-22, 2017, the facility failed to update treatment plans every 60 days.Client #2 was admitted on July 20, 2015 and discharged on February 15, 2017. A treatment plan update was documented on September 22, 2017 and the next one was not documented until February 13, 2017.Client #3 was admitted on May 16, 2014 and discharged on June 27, 2017. The last treatment plan update was documented on February 16, 2017.Client #4 was admitted on May 14, 2014 and discharged on May 23, 2017. The last treatment plan update was documented on December 30, 2017.Client #8 was admitted on April 27, 2017. The comprehensive treatment plan was documented on June 27, 2017 and the treatment plan update wasn't documented until September 14, 2017. Client #9 was admitted on February 23, 2017. One treatment plan update was documented on May 18, 2017 and the last one wasn't documented until July 31, 2017.Client #10 was admitted on June 15, 2017. The comprehensive treatment plan was documented on July 7, 2017 and the treatment plan update wasn't documented until September 14, 2017.The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor met with the staff on 10/19/2017 to review this deficiency. Counselors were instructed to run monthly reports of services due via the Methasoft EMR system.
Counselors will review treatment plans at least two times per month with the client. Counselors will place clients on medication hold the week the treatment plans are due, if necessary.
The Clinical Supervisor will monitor the completion of treatment plans during individual supervision with the Counselors.
Random monthly chart reviews will also be done by the Clinical Supervisor to assure continued compliance. The results of the treatment plans will be reported to the Performance Improvement Committee for the next six (6) months. |
711.93(a) LICENSURE Complete Client Record
711.93. 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 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 21-22, 2017, the facility failed to document a complete client record in all records reviewed when it centers around the client ' s record of service, discharge summary, and follow-up. The client's record of service was not documented as of the date of the licensing inspection in client records, #3-13.Client #2 was admitted on July 20, 2015 and discharged on February 15, 2017. The facility failed to document a discharge summary.Client #3 was admitted on May 16, 2014 and discharged on June 27, 2017. The facility failed to document a discharge summary.Client #4 was admitted on May 14, 2014 and discharged on May 23, 2017. The facility failed to document a discharge summary and follow-up.Client #5 was admitted on June 29, 2017 and discharged on July 28, 2017.Client #6 was admitted on July 8, 2017 and discharged on August 29, 2017.Client #7 was admitted on May 30, 2017.Client #8 was admitted on April 27, 2017.Client #9 was admitted on February 23, 2017.Client #10 was admitted on June 15, 2017.Client #11 was admitted on July 13, 2017.Client #12 was admitted on August 8, 2011.Client #13 was admitted on October 20, 2013.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #2 was admitted on July 20, 2015 and discharged on February 15, 2017. The facility failed to document a discharge summary.
The Discharge Summary was completed on this client and is in the EMR system. Date of Discharge Summary is 2/15/17. This particular chart is both paper and EMR chart.
Client #3 was admitted on May 16, 2014 and discharged on June 27, 2017. The facility failed to document a discharge summary.
The Discharge Summary was completed on this client and is in the EMR system. Date of Discharge Summary is 6/27/17. This particular chart is both paper and EMR chart.
Client #4 was admitted on May 14, 2014 and discharged on May 23, 2017. The facility failed to document a discharge summary and follow-up.
The Discharge Summary was completed on this client and is in the EMR system. Date of Discharge Summary is 5/23/17.
However, the follow up was not done. Counselor has since completed the follow up effective 10/25/17.
The client's record of service was not documented as of the date of the licensing inspection in client records, #3-13.
Client #5 was admitted on June 29, 2017 and discharged on July 28, 2017.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through July 28, 2017. The Administrative Assistant was trained by a Methasoft Representative on 10/25/17 on how to export this information from the EMR. The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #6 was admitted on July 8, 2017 and discharged on August 29, 2017.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through August 29, 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #7 was admitted on May 30, 2017.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through September 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #8 was admitted on April 27, 2017.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through September 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #9 was admitted on February 23, 2017.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through September 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #10 was admitted on June 15, 2017.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through September 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #11 was admitted on July 13, 2017.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through September 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #12 was admitted on August 8, 2011.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through September 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
Client #13 was admitted on October 20, 2013.
The Record of Service could not be printed for the inspector at the time of the inspection, however, the Record of Service is available in the EMR through September 2017. The Administrative Assistant has been trained by a Methasoft Representative on how to export this information from the EMR.The Hospital will assure an employee is available to assist inspectors through the EMR for all future inspections.
The Clinical Supervisor met with the staff on 10/19/17 to review this deficiency.
Counselors will complete all discharge paperwork(discharge summary, continuing care plan, follow up form) within 7 days of the discharge date. Counselors will inform the Clinical Supervisor regarding the discharge of the client immediately.
The Clinical Supervisor will monitor continued compliance by conducting chart reviews and report the results of the reviews to the Performance Improvement Committee for the next six (6) months.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
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:
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Observations
Based on a review of thirteen client records on September 21-22, 2017, the facility failed to ensure the client's confidentiality in records, #1, 4, 6, 8 and 9.Client #1 was admitted on February 3, 2012 and discharged on January 30, 2017. A letter dated December 7, 2016, was sent out addressed "To Who It May Concern". Could not verify if a consent to release was on file for this agency. Client #4 was admitted on May 14, 2014 and discharged on May 23, 2017. A consent to release to a transportation agency dated May 13, 2016 did not have the counselor's signatureClient #6 was admitted on July 8, 2017 and discharged on August 29, 2017. Four consents to release forms, for two funding sources, one for a transportation agency and one for the client's emergency contact, had the client's date of signature as July 14, 2017 and the counselor's signature date as July 11, 2017. Client #8 was admitted on April 27, 2017. Four consents to release forms, for two funding sources, one for a transportation agency and one for the client's emergency contact, had the client's date of signature as April 27, 2017 and the counselor's signature date as May 1, 2017. Client #9 was admitted on February 23, 2017. A consent to release for the client's emergency contact had the client's date of signature as March 3, 2017 and the counselor's signature date as March 8, 2017. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In both cases of client #8 and client #9, staff members signed the Consent forms later than the client.
In order to correct this deficiency, the Clinical Supervisor in-serviced the Counselors on 10/26/17 on how to create an appropriate Release of information form and how to formally address the recipient of where information is being sent. Also Counselors were re-educated to have all consent forms signed concurrently by the staff member and the client.
In order to assure continued compliance, the Clinical Supervisor will conduct random monthly chart reviews. The results of these chart reviews will be forwarded to the Performance Improvement Committee for the next six (6) months. |