INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on April 28-29, 2009 by staff from the Division of Drug and Alcohol 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 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and plan of correction is due on May 20, 2009.
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Plan of Correction
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on the review of patient records, the facility failed to complete consents to release information according to in four of five records reviewed.
The findings include:
Five patient records were reviewed on April 28-29, 2009. Fully documented consents to release information was required in five patient records. The facility did not document all the required components in two patient records, # 2 and 3. The facility did not present full disclosure of what information would be released to a funding entity in two patient records, # 4 and 5.
Records # 2 and 3 had consents to release information with the purpose of continuing care post discharge. The consent did not specify who the information was going to was not documented prior to the patient signing.
Record # 4 had a consent to release information for the patient's funding company, but the information listed for release was restricted to the patient's diagnosis and PCPC scores without consent to disclose the patient's presence in the program.
Record # 5 had a consent to release information for the patient's funding company, but the information listed for release was restricted to the patient's PCPC scores without consent to disclose the patient's presence in the program.
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Plan of Correction
Staff was in-serviced by the Clinical Supervisor by 5/18/09 on proper completion of consent forms and Federal Confidentiality requirements. The Clinical Supervisor will monitor for improvement via weekly chart reviews for a period of six (6) months (11/09). |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document psychosocial evaluations in three of four patient records.
The findings include:
Five patient records were reviewed on April 28-29, 2009. Psychosocial evaluations were required in four patient records. The narcotic treatment program did not include evaluations in all the required areas in the psychosocial evaluation in patient records #1, 3 and 5.
In patient records 1, 3 and 5 the psychosocial evaluations did not include an evaluation of the patient problems/needs, assets/strengths, support systems, coping mechanism, factors that may inhibit treatment or recommendations. Instead, the documentation was a repeat of the data already collected and documented.
In patient record # 5, there was more data in the evaluation than in the history itself, and some of the evaluation contradicted what was written in the history.
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Plan of Correction
Counselor was in-serviced on the proper completion of Bio Psychosocial Evaluations by the Clinical Supervisor on 5/16/09. Counselor also received official training by CBH. The Clinical Supervisor will monitor for improvement through random chart reviewes for a period of six (6) months (11/09). |
715.24(3) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(3) A 1-year physiologic dependence is not required for narcotic detoxification although documentation of current dependency is required.
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Observations
Based on the review of patient records, the facility failed to accurately document current dependency in two of five patient records.
The findings include:
Five patient records were reviewed on April 28-29, 2009. Five records required documentation of current dependency. The facility failed to appropriately document the findings of current dependency in patient records # 2 and 3. The facility uses a check list of four potential signs of current dependency that include patient statement, early withdrawal symptoms, positive for opiates urine drug screen and an option for "other" with examples of fresh track marks, abscesses, etc. The physician checked off all boxes without the benefit of supporting documentation.
Record # 2 had all four boxes checked, including having a positive for opiates urine drug screen and fresh track marks. This patient tested negative for all substances and she ingested orally a prescription narcotic drug.
Record # 3 had all four boxes checked, including the "other" box without specifying what other symptoms were being used to determine current dependency as the supporting documentation; the patient had ingested narcotic substances via his nasal passage.
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Plan of Correction
An in-service will be given to physicians by Yulisa Rios, Clinical Supervisor, to be more accurate with documentation of the current dependency by 5/29/09. A random chart review will be done within 30 days by the Performance Improvement to assure full compliance. |