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 January 18-19, 2012 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.
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Plan of Correction
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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 the review of patient records, the facility failed to ensure the patient signed the informed, voluntary, written consent prior to the administration of a narcotic agent in two of eight patient records.
The findings include:
Eight patient records were reviewed on January 18-19, 2012. Informed consent documentation was reviewed in eight patient records. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient records # 6 and 8.
Patient # 6 was admitted into treatment on January 18, 2012. The patient received his/her initial dose of methadone on January 18, 2012. The informed consent was signed January 19, 2012, a day after the initial dose was given to the patient.
Patient # 8 was admitted into treatment on January 18, 2012. The patient received his/her initial dose of methadone on January 18, 2012. The informed consent was signed January 19, 2012, a day after the initial dose was given to the patient.
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Plan of Correction
We provide informed, voluntary written consent before any MAT begins either for maintenance or detoxification treatment.
The importance of having signed consent was discused at a staff meeting on 02/03/12.
The Lead assessor in our AIU was empowered to make sure that each patient presenting for detox treatment in medication assisted treatment was informed of this process and a consent is signed by that patient and witness by the medical director.
The Director of Behavioral Services will monitor for compliance with this process.
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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 review of the patient records, and discussion with medical personnel, the facility failed to obtain a complete drug screen urinalysis prior to the administration of a narcotic agent in seven of eight patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Eight patient records were reviewed on January 18-19, 2012. Eight patient records were required to have a completed drug screen urinalysis prior to the administration of a narcotic agent. Seven of the patient records reviewed did not include the final results from the CLIA and Department of Health approved laboratory.
Three of the patient records included a form entitled "Preliminary Report-Do Not Chart" that listed the results that were read in the onsite laboratory. These results are sent offsite for confirmation. The final report was not found for records # 6, 7 and 8, but the preliminary results report was in each of these three records. This was discussed and confirmed by the medical director of the onsite, CLIA and Department of Health approved laboratory.
Patient # 1 was admitted on November 30, 2011. The initial dose of methadone was given on November 30, 2011. The urine drug screen report was completed December 1, 2011.
Patient # 2 was admitted on November 17, 2011. The initial dose of methadone was given on November 17, 2011. The urine drug screen report was completed November 18, 2011.
Patient # 3 was admitted on October 25, 2011. The initial dose of methadone was given on October 25, 2011. The urine drug screen report was completed October 26, 2011.
Patient # 4 was admitted on August 27, 2011. The initial dose of methadone was given on August 27, 2011. The urine drug screen report was completed August 29, 2011.
Patient # 6 was admitted on January 18, 2012. The initial dose of methadone was given on January 18, 2012. The urine drug screen report was not completed at the time of the inspection, January 19, 2012.
Patient # 7 was admitted on January 18, 2012. The initial dose of methadone was given on January 18, 2012. The urine drug screen report was not completed at the time of the inspection, January 19, 2012.
Patient # 8 was admitted on January 18, 2012. The initial dose of methadone was given on January 18, 2012. The urine drug screen report was not completed at the time of the inspection, January 19, 2012.
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Plan of Correction
The Hospital sent a letter to the Department of Health, Division of Drug & Alcohol Licensure, on 2/3/12 requesting an Exception for Laboratory Testing of Urine Drug Screens. The Hospital is awaiting a response.
Until a response is received from the Department of Health, Kensington Hospital will not administer a narcotic agent until a complete urine drug screen is done and results received.
A meeting was also held at Kensington with the CEO, Program Director and Atlantic Lab Personnel and agreement was made that all labs reports will be fax to admission verifiying the present of narcotic in the patients system that will required methadone assisted treatment. This will be over seen by the Medical Director of addiction serivices and the Director of Behavioral services. |
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 and administrative documentation, the facility failed to ensure the psychosocial evaluations were an evaluation of the collected historical data and completed within 48 hours, in five of five patient records reviewed.
The findings include:
Eight patient records were reviewed January 18-19, 2012. Five records were reviewed for psychosocial evaluations.
The policy and procedure manual was reviewed January 18, 2012. The policy regarding the psychosocial evaluation stated it was to be completed within 48 hours of admission.
Patient # 1 was admitted November 30, 2011. The psychosocial evaluation was completed December 1, 2011 and failed to evaluate the historical data collected. Instead, it was a repeat of the data and a collection of what the patient reported.
Patient # 2 was admitted November 17, 2011. The psychosocial evaluation was completed November 18, 2011 and failed to evaluate the historical data collected. Instead, it was a repeat of the data and a collection of what the patient reported.
Patient # 3 was admitted October 25, 2011. The psychosocial evaluation was completed October 25, 2011 and failed to evaluate the historical data collected. Instead, it was a repeat of the data and a collection of what the patient reported.
Patient # 4 was admitted January 16, 2012. The psychosocial evaluation was to be completed by January 18, 2012. It was not completed at the time of the inspection of the record, January 19, 2012.
Patient # 5 was admitted January 18, 2012. The psychosocial evaluation was completed January 18, 2012 and failed to evaluate the historical data collected. Instead, it was a repeat of the data and a collection of what the patient reported.
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Plan of Correction
A staff meeting was held on 03/09/12 and part of the agenda included the correct way to use an assessment tool to complete a client assessment. The staff was shown how to interpret client responses to questions in the history taken by giving insighful assessment the process of determining affective treatment plan will be enhanced. The director of behavioral services will continue to monitor and improve staff interpretations to insure appropiate treatment planning and aftercare. |