INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 7-8, 2014 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to have a written individual training plan for each employee in four of six personnel records reviewed.
The findings include:
The facility's SRFSR and six personnel records were reviewed for documentation of a written individual training plan. The facility failed to ensure that employees # 5, 6, 7, and 8 had an individual training plan.
Employee # 5 was hired as the Medical Director on July 25, 2001. Personnel record # 5 did not include documentation of an individual training plan as of August 6, 2014.
Employee # 6 was hired as a Physician on September 8, 2011. Personnel record # 6 did not include documentation of an individual training plan as of August 6, 2014.
Employee # 7 was hired as a Medicating Nurse on March 17, 2001. Personnel record # 7 did not include documentation of an individual training plan as of August 6, 2014.
Employee # 8 was hired as an Administrative Assistant on March 21, 2003. Personnel record # 8 did not include documentation of an individual training plan as of August 6, 2014.
The findings were confirmed by the facility director on August 6, 2014.
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Plan of Correction
The program will ensure that each staff member has an individual training plan. The Director of Behavioral Health Services will complete training plans with employees in the Behavioral Health Department. The Director of Nursing will complete training plans with employees in the Nursing Department. The Medical Director will complete training plans with the program physicians. The program will be in compliance by October 17, 2014. All training plans will be updated in January 2015 for the 2015 training year. |
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 patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician in two of six records reviewed.
The findings include:
Six patient records requiring documentation of an annual reevaluation by the narcotic treatment physician were reviewed from August 7, 2014 to August 8, 2014. The facility failed to a document an annual reevaluation in patient records # 5 and 12.
Patient # 5 was admitted September 4, 2012 and was still an active patient as of 8/8/14. A physical examination was completed upon patient # 5's admission. An annual reevaluation was due in September 2013. However, patient record # 5 did not include documentation of a reevaluation as of August 8, 2014.
Patient # 12 was admitted December 23, 2010 and was discharged February 27, 2014. A physical examination was completed October 24, 2012. An annual reevaluation was due October 24, 2013. However, patient record # 12 did not include documentation of a reevaluation as of August 8, 2014.
The findings were confirmed by the facility director on August 8, 2014.
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Plan of Correction
The program Administrative Assistant will compile a monthly list of clients who have admission anniversaries in the next month. This list will be sent to the Counselors/Therapists, the Program Physician, and the Director of Behavioral Health Services. The program Administrative Assistant will schedule appointments for each client to meet with the Program Physician for the annual physical examination. The list will be reviewed at the end of the month to ensure that the scheduled annual physical is completed for all assigned clients. The program will be in compliance by October 31, 2014. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on an interview with the facility director and a review of an unusual incident report, the facility's narcotic treatment program failed to implement policies and procedures that respond to a patient's death.
The findings include:
On August 7, 2014, the License Specialist asked the facility director if the facility had any unusual incidents of a patient's death. The facility director informed the License Specialist that the facility had an unusual incident of a patient's death on December 28, 2013. The facility did complete an unusual incident report on February 4, 2014. However, the facility did not send the unusual incident report to the Department.
The findings were confirmed by the facility director on August 7, 2014.
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Plan of Correction
The Director of Behavioral Health Services will complete unusual incident reports as needed in compliance with the regulation. The current Director has worked with the Department to complete outstanding reports from the previous administration. The cited missing unusual incident report was completed and received by the Department on 09/11/2014. To ensure that the deficiency does not recur, fax or email confirmation pages will be kept with the incident report in the incident report binder. The Program will be in compliance as of 09/15/2014. |
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 a review of patient records, the facility failed to document a psychosocial evaluation of the patient in six of eleven patient records reviewed.
The findings include:
Eleven patient records requiring documentation of a psychosocial evaluation were reviewed from August 7, 2014 to August 8, 2014. The facility failed to a document psychosocial evaluation in patient records # 1, 4, 9, 11, 13, and 14.
Patient # 1 was admitted April 23, 2014 and was still an active patient. The psychosocial evaluation was due April 24, 2014. However, patient record # 1 did not include documentation of a psychosocial evaluation as of August 8, 2014.
Patient # 4 was admitted April 16, 2014 and was still an active patient as of 8/8/14. The psychosocial evaluation was due April 17, 2014. However, patient record # 1 did not include documentation of a psychosocial evaluation as of August 8, 2014.
Patient # 9 was admitted July 15, 2014 and was still an active patient as of 8/8/14. The psychosocial evaluation was due July 16, 2014. However, patient record # 9 did not include documentation of a psychosocial evaluation as of August 8, 2014.
Patient # 11 was admitted June 3, 2014 and was still an active patient as of 8/8/14. The psychosocial evaluation was due June 4 16, 2014. However, patient record # 11 did not include documentation of a psychosocial evaluation as of August 8, 2014.
Patient # 13 was admitted April 16, 2014 and was discharged July 15, 2014. The psychosocial evaluation was due April 17, 2014. However, patient record # 13 did not include documentation of a psychosocial evaluation as of August 8, 2014.
Patient # 14 was admitted March 11, 2014 and was discharged May 2, 2014. The psychosocial evaluation was due March 12, 2014. However, patient record # 14 did not include documentation of a psychosocial evaluation as of August 8, 2014.
The findings were confirmed by the facility director on August 8, 2014.
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Plan of Correction
Kensington Hospital policy states, "The psychosocial evaluations should be completed by the assigned counselor within the first 30 days of treatment." This policy is in compliance with the Department of Drug and Alcohol Programs' regulation 711.91(b)(6).
The Director of Behavioral Health Services will provide supervision and training to the counselors on the topic of assessment and evaluation. The Administrative Assistant will present newly admitted charts to the Director of Behavioral Health Services thirty days after admission review. The chart will be reviewed for compliance with the psychosocial evaluation policy. Training will be presented on September 29, 2014. Supervision will occur on an ongoing basis. Chart checks will start immediately.
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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 document treatment and rehabilitation plan updates at least every 60 days in four of nine patient records reviewed.
The findings include:
Nine patient records requiring documentation of treatment and rehabilitation plan updates were reviewed from August 7, 20104 to August 8, 2014. The facility failed to document a treatment and rehabilitation update at least every 60 days in patient records # 1, 4, 7, and 8.
Patient # 1 was admitted April 23, 2014 and was still an active patient as of 8/8/14. A treatment plan update was completed May 22, 2014 and another treatment plan update was due July 22, 2014. However, patient record # 1 did not include documentation of an additional treatment plan update as of August 8, 2014.
Patient # 4 was admitted April 16, 2014 and was still an active patient as of 8/8/14. A treatment plan update was completed May 21, 2014 and another treatment plan update was due July 21, 2014. However, patient record # 4 did not include documentation of an additional treatment plan update as of August 8, 2014.
Patient # 7 was admitted December 18, 2013 and was still an active patient as of 8/8/14. A treatment plan update was completed February 7, 2014 and another treatment plan update was due April 7, 2014. However, the additional treatment plan update was not completed until June 23, 2014.
Patient # 8 was admitted September 4, 2013 and was still an active patient as of 8/8/14. A treatment plan update was completed May 28, 2014 and another treatment plan update was due July 28, 2014. However, patient record # 8 did not include documentation of an additional treatment plan update as of August 8, 2014.
The findings were confirmed by the facility director on August 8, 2014.
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Plan of Correction
The Director of Behavioral Health Services will provide supervision and training to the counselors/therapists on the topic of treatment planning. The Director will review the regulation regarding 60-day treatment plan updates during a staff meeting on 9/29/2014. Supervision will occur on an ongoing basis. The Lead Therapist and Director of Behavioral Health Services will conduct random chart checks weekly to ensure compliance with the regulation. The Program will be in compliance by 10/31/2014. |