Observations
On November 14, 2017 DDAP staff conducted a telephone interview with facility staff. In addition, facility policies were reviewed. Based on a review of this information , the facility failed to adhere to the conditions for involuntary termination as delineated in regulation. The facility's "Fee and Payment" policy indicated that "failure to respond to a notice of financial probation will result in you being terminated from the program." Facility staff also reported that a client with an outstanding financial obligation would not receive their daily dose.
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Plan of Correction
With regard to this incident, the employee who made the decision not to dose this client made the decision without the approval of Hospital Administration.
Effective 11/30/17, Kensington Hospital has hired a new Program Director to assure the compliance of all Policies & Procedures of the Program.
The employee who made the decision not to dose the client was counseled by her Supervisor.
Also, this particular client has been reporting to the Outpatient Treatment Program on a daily basis to receive her daily doses of methadone since 11/24/17.
The Program staff will be re-educated by the new Program Director on the Policy & Procedure of Involuntary Terminations by 12/08/17.
The Program Director will review charts on clients with outstanding financial obligations to Program in order to assure the Program's Policy & Procedure on Involuntary Terminations is being followed. The results of these monthly chart reviews will be reported to the Performance Improvement Committee for the next six (6) months to assure continued compliance in this area.
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