INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 4, 2022 through October 5, 2022 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that frozen food was kept at or below 0 degrees Fahrenheit. At approximately 1:30 PM on October 5, 2022, the freezer temperature was measured at 15 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
Upon discovery of the freezer not maintaining the proper temperature on 10/5/2022, the Hospital's Refrigeration company was contacted for service. A technician promptly arrived at the Hospital on 10/5/2022. A part was ordered and installed the following day (October 6, 2022).
The dietary staff immediately relocated all frozen food to Dietary's secondary freezer until 10/6/2022 when the primary freezer was repaired.
In order to assure continued compliance, the Dietary staff were in-serviced by the Dietary Manager on 10/6/2022 to monitor and document the freezer's temperature as follows:
Monitor & document the freezer temperature at 7:00AM, 12:00 Noon & 5:00PM. Documentation will be made on the Freezer Temperature Log (located on a clipboard on the freezer door).
The Dietary Manager will monitor the results and they will be presented to the Performance Improvement Committee on a quarterly basis.
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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 an informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in two of twenty patient records reviewed.
Patient # 12 was admitted to the inpatient non-hospital detoxification activity on April 8, 2022 and was discharged on April 13, 2022. There was no documentation of an informed, voluntary, written consent, in the patient record, before an agent was administered to the patient for detoxification.
Patient # 13 was admitted to the inpatient non-hospital detoxification activity on February 9, 2022 and was discharged on February 14, 2022. There was no documentation of an informed, voluntary, written consent, in the patient record, before an agent was administered to the patient for detoxification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services in-serviced the Admissions Intake Staff on 10/10/2022 to be reminded to always obtain the patient's informed, voluntary, written consent before a narcotic agent may be administered to the patient for maintenance or detoxification treatment.
In order to assure continued compliance, the Director of Behavioral Health Services will review a sampling of monthly charts to assure patients have the informed, voluntary, written consent at the time of intake. The results from this monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis.
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711.62(c)(2) LICENSURE Informed & Voluntary Consent
711.62. 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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 13 was admitted to the inpatient non-hospital detoxification activity on February 9, 2022 and was discharged on February 14, 2022. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services in-serviced the Admissions Intake Staff and the inpatient Counselors on 10/10/2022 to complete an informed and voluntary consent to release information form prior to the disclosure of information.
In order to assure continued compliance, the Director of Behavioral Health Services will review monthly charts to assure staff completed an informed and voluntary consent to release information form prior to the disclosure of information
Monthly monitoring results will be reported to the Performance Improvement Committee on a quarterly basis.
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711.63(e) LICENSURE Follow-up Policy
711.63. Project management services.
(e) The project shall develop a written client follow-up policy.
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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 #8 was admitted to the inpatient non-hospital detoxification activity on June 23, 2022 and was discharged against medical advice on June 25, 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
The Director of Behavioral Health Services in-serviced the Counseling and Nursing Staff on 10/10/2022 to notify the patient's emergency contact when a patient leaves against medical advice. The notification of the emergency contact must also be documented in the medical record.
In order to assure continued compliance, the Director of Behavioral Health Services will review monthly charts to assure staff are notifying the patient's emergency contact when they leave AMA and documenting that notification in the medical record.
Monthly monitoring results will be reported to the Performance Improvement Committee on a quarterly basis.
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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 the dated signature of the client on a release of information form in one of seven client records reviewed.
Client # 17 was admitted to the inpatient non-hospital activity on December 12, 2021 and was discharged on December 14, 2021. The release of information form to another treatment provider was signed and dated by a witness on December 14, 2021, but the form did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services in-serviced the Admissions Intake Staff and the inpatient Counseling Staff on 10/10/2022 that a patient's signature and date must be documented on all Release of Information forms to another treatment provider.
In order to assure continued compliance, the Director of Behavioral Health Services will review monthly charts to assure the patient's signature and the date is on the Release of Information form to another treatment provider.
Monthly monitoring results will be reported to the Performance Improvement Committee on a quarterly basis to assure continued compliance.
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710.22(c) LICENSURE Patient Management Services
§ 710.22. Patient management services.
(c) The service staff shall develop a written patient follow-up policy.
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Observations
Based on a review of patient records, the facility failed to follow the written patient follow-up policy in two of two 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.
Patient #3 was admitted to the inpatient hospital detoxification activity on July 5, 2022 and was discharged against medical advice on July 7, 2022; however, there was no documentation that the emergency contact was notified of the client's discharge as of the date of the inspection.
Patient #5 was admitted to the inpatient hospital detoxification activity on July 19, 2022 and was discharged against medical advice on July 23, 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
The Director of Behavioral Health Services in-serviced the Counseling and Nursing Staff on 10/10/2022 to notify the patient's emergency contact when a patient leaves against medical advice. The notification of the emergency contact must also be documented in the medical record.
In order to assure continued compliance, the Director of Behavioral Health will review monthly charts to assure staff are notifying the patient's emergency contact as well as documenting the notification in the medical record when they leave AMA.
Monthly monitoring results will be reported to the Performance Improvement Committee on a quarterly basis.
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