INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on September 17, 2024 through September 18, 2024 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 Outpatient Treatment Program 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel records reviewed.
Employee # 8 was hired as a counselor on November 16, 2022 and was due to receive the HIV/AIDs training and the TB/STD training no later than November 16, 2023. The employee did complete the HIV/AIDS training; however, there was no documentation, in the personnel record, that the TB/STD training was completed as of the date of the inspection.
This is a repeat citation from the October 12, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) The Assistant Director of Behavioral Health Services met individually with this particular counselor on 9/26/2024. The Counselor is now scheduled for the TB/STD training on 10/28/2024 and will provide a Training Certificate and Training Feedback Form for her personnel file.
2) In order to assure future compliance, the Assistant Director will review training needs for each counselor during their individual supervision session each month to ensure the trainings are completed within the required time period.
3) The Director of Behavioral Health Services will also maintain an audit of counselors' annual trainings to ensure they are completed before they are due.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2023 through December 31, 2023 training year in one of three applicable personnel records reviewed.
Employee # 7 was hired as a counselor on January 2, 2020. The personnel record documented 2 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Assistant Director of Behavioral Health Services met with the one (1) particular employee on 9/26/2024 who was non-compliant in obtaining the required 25 hours of training in 2023 to review this citation. The employee had a disciplinary write up placed in his personnel file. The employee acknowledged the importance and understanding he must obtained the required training hours or further disciplinary action would be taken.
The Assistant Director also met with the Counseling staff as a whole to also review the citation and the importance of obtaining their required training hours.
In order to monitor this plan of correction, the Assistant Director of Behavioral Health developed a spreadsheet to monitor each employees' hours of training.
The Counseling staff was also instructed to have their 25 hours of training completed no later than 11/30 of each training year to assure future compliance.
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711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for not providing an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment, with 1 hour of which shall be individual psychotherapy, was submitted and approved by the Department for the May 20, 2021, October 21, 2021, October 25, 2022, and October 12, 2023 annual licensing inspections. Not providing an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment, with 1 hour of which shall be individual psychotherapy, was again found to be a deficiency in the September 17, 2024 through September 18, 2024 licensing inspection.
A plan of correction for obtaining a random drug screen urinalysis at least once a month was submitted and approved by the Department for the May 20, 2021, October 21, 2021, October 25, 2022, and October 12, 2023 annual licensing inspections. Not obtaining a random drug screen urinalysis at least once a month was again found to be a deficiency in the September 17, 2024 through September 18, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services met with the Assistant Director on 9/26/2024 to review this citation. The Assistant Director was instructed to:
1) Run a report on the EMR on the 15th of each month to calculate how many group and individual hours have been completed for each client
2) The mid-month report will then be reviewed with the Counselors during individual supervision. Clients not meeting hours will be reviewed and scheduled accordingly.
3) No Show notes and/or re-scheduled sessions will be recorded in client's charts to show attempts to engage the client for treatment.
4) The Assistant Director of Behavioral Health will complete a monthly Performance Improvement Study to assure the counselors are providing at least 2.5 hours of treatment for each client. The results of this monthly monitoring will be forwarded to the Performance Improvement Committee on a quarterly basis.
5) The CEO and Medical Director will review the recent DDAP inspection report along with the approved plans of correction to assure that those approved plans of correction are strictly followed in efforts to achieve compliance. The monthly reviews by the CEO & Medical Director will also be reported to the Performance Improvement Committee at their quarterly meetings. |
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 narcotic treatment program failed to complete an initial drug-screening urinalysis for each perspective patient and a random urinalysis at least monthly in one of seven patient records reviewed.
Patient # 3 was admitted on December 12, 2023 and was active at the time of inspection. There was no documentation, in the record, indicating the initial drug-screen urinalysis was completed upon admission. Additionally, there was no documentation, in the record, of a drug-screen urinalysis completed during the months of December 2023, January 2024, and February 2024.
This is a repeat citation from the May 20, 2021, October 21, 2021, October 25, 2022, and October 13, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Assistant Director of Behavioral Health Services in-serviced the Counseling Staff on 9/26/2024 to remind the staff on the following:
1) An initial drug screening urinalysis must be completed on all new clients to the Program.
2) A random urinalysis is done on each client on a monthly basis.
In order to assure future compliance, the Performance Improvement Coordinator will monitor medical records on a monthly basis to assure 1) an initial drug screening urinalysis is completed on new clients to the Program and 2) a random urinalysis is completed once a month on all clients.
The results of this monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure the narcotic treatment physician reviewed the dosage levels at least twice a year, with each review occurring at least 2 months apart, in one of four applicable patient records reviewed.
Patient # 7 was admitted on November 17, 2019 and was discharged on May 8, 2024. There was no documentation, in the record, of a semi-annual dosage review being completed prior to the patient's discharge.
This is a repeat citation from the October 12, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Kensington Hospital's Medical Director met with the Narcotic Treatment Physician on 9/26/2024 to review this citation. The Narcotic Treatment Physician was reminded to review client dosage levels twice a year, with each review being at least 2 months apart.
The Assistant Director of Behavioral Health Services will insert "flags" in the EMR as to alert the Narcotic Treatment Physician when he needs to review a client's dosage levels (twice a year) and those reviews are done at lease 2 months apart.
In order to effectively evaluate compliance, the Performance Improvement Coordinator will monitor medical records monthly to assure the Narcotic Treatment Physician is reviewing clients' dosage levels twice a year, with each review being at least 2 months apart.
The results from this PI Study will be presented to the Performance Improvement Committee on a quarterly basis.
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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 patient records, the narcotic treatment program failed to provide each patient an average of 2.5 hours of psychotherapy per month, during their first 2 years in treatment, 1 hour of which shall be individual psychotherapy, in one of four applicable patient records reviewed.
Client # 2 was admitted on March 7, 2024 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of August 2024, there was more than 2.5 hours of psychotherapy services provided to the patient; however, there was documentation that only 30 minutes of individual therapy was provided.
This is a repeat citation from the May 20, 2021, October 21, 2021, October 25, 2022, and October 12, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services met with the Assistant Director on 9/26/2024 to review this citation. The Assistant Director was instructed to:
1) Run a report on the EMR on the 15th of each month to calculate how many group and individual hours have been completed for each client
2) The mid-month report will then be reviewed with the Counselors during individual supervision. Clients not meeting hours will be reviewed and scheduled accordingly.
3) No Show notes and/or re-scheduled sessions will be recorded in client's charts to show attempts to engage the client for treatment.
4) The Assistant Director of Behavioral Health will complete a monthly Performance Improvement Study to assure the counselors are providing at least 2.5 hours of treatment for each client. The results of this monthly monitoring will be forwarded to the Performance Improvement Committee on a quarterly basis.
Back to Survey Selection Back to Deficiency Listing
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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 client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of six applicable client records reviewed.
Client # 1 was admitted on September 27, 2016 and was still active at the time of the inspection. A treatment plan update was completed on June 13, 2024 and the next update was due no later than August 13, 2024; however, the update was not completed until September 6, 2024.
Client # 2 was admitted on March 7, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 1, 2024 and the first update was due no later than September 1, 2024; however, the update was not completed until September 11, 2024.
Client # 3 was admitted on December 12, 2023 and was active at the time of inspection. A treatment plan update was completed on March 19, 2024 and the next update was due no later than May 19, 2024; however, the update was not completed until May 30, 2024. Additionally, the next treatment plan update was due no later than July 30, 2024; however, the update was not completed until August 7, 2024.
This is a repeat citation from the October 12, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Assistant Director of Behavioral Health Services met and in-serviced the Counseling staff on 9/26/2024 on the regulatory requirement that Treatment and Rehabilitation Plans must be reviewed and updated within 60 days.
The Performance Improvement Coordinator will monitor medical records on a monthly basis to assure the counselor are updating the Treatment and Rehabilitation Plans every 60 days.
The results of the monthly monitoring will be forwarded to the Performance Improvement Committee on a quarterly basis. |
711.93(a)(7) LICENSURE Follow-up Information
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:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow up information, in two of four applicable client records reviewed.
Client # 4 was admitted on December 31, 2021 and was discharged on December 18, 2023. There was no follow-up information documented in the record at the time of the inspection.
Client # 6 was admitted on February 23, 2017 and was discharged on February 28, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counseling Staff were in-serviced by the Assistant Director of Behavioral Health Services on 9/26/2024. Counselors were reminded and instructed they must include follow up information in the client's medical record.
In order to assure compliance, the Performance Improvement Coordinator will review medical charts on a monthly basis to assure the Counselors are documenting following up information in the client's medical chart.
The results from the monthly monitoring will be presented to the Performance Improvement Committee at their quarterly meetings.
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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 client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 2 was admitted on March 7, 2024 and was still active at the time of the inspection. There was evidence of a disclosure to another treatment provider on March 7, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/26/2024, the Assistant Director of Behavioral Health Services met and in-serviced the Counseling staff on the importance of obtaining an informed and voluntary consent to release information form prior to the disclosure of information contained in the client record.
To evaluate the effectiveness of compliance, the Performance Improvement Coordinator will review medical records to assure that the Counseling staff are obtaining the informed and voluntary consent to release information form prior to the disclosure of information contained in the client's record.
The results will be forwarded to the Performance Improvement Committee at the quarterly Performance Improvement Committee meetings. |