INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10-11, 2015 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 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that each counselor receive at least 25 clock hours of training annually in one of one record reviewed.
The findings include:
According to the Staffing Requirements Facility Summary Report, the facility training year runs from January 1 through December 31.
One counselor's record was reviewed specifically for training hours for the 2014 training year on August 10, 2015. Employee #3 was promoted to the position of counselor on April 12, 2010. Employee # 3 had only 21 documented clock hours of training during January 1, 2014 through December 31, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant to the Director of Behavioral Health Services will track the hours of training for employees. The Administrative Assistant will update the training hours monthly and present a report of total training hours monthly to the Director of Behavioral Health Services. Trainings will be scheduled by the Director of Behavioral Health Services based on the need of the employee. The facility will be in compliance by 12/31/2015, the end of the 2015 training year. |
711.62(a)(6) LICENSURE Follow-up Information
711.62. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Follow-up information.
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Observations
Based on the review of patient records the facility failed to ensure that a complete record was documented in two out of eight patient records reviewed.
The findings include:
Four patient records were reviewed for documentation of a follow-up on August 11, 2015. The facility failed to document a follow-up attempt in two out of four discharged records, specifically client records #6 and 7.
Client #6 was admitted on 2/2/15 and discharged on 2/8/15. As of the date of inspection, there was no documentation of a follow-up attempt for client #6.
Client #7 was admitted on 1/22/15 and discharged on 4/15/15. As of the date of inspection, there was no documentation of a follow-up attempt for client #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors received training about follow-up on 8/13/2015 from the Director of Behavioral Health Services. Counselors understand that follow-up must occur with every discharged patient within seven days of discharge. The follow up forms are to be kept as part of the patient chart. The Medical Records Supervisor will monitor the charts for compliance. Any further compliance issues will be communicated to the Director of Behavioral Health Services. The Director of Behavioral Health Services will provide supervision and training regarding follow-up as needed. The facility will be in compliance by 9/3/2015. Follow up for both clients was completed and documented by the counselor on 9/9/15. |
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 the patient records, the facility failed to document consents to release information which include the name of the person agency, or organization to which the disclosure is made, the specific information to be disclosed, and/or the purpose of the disclosure in one of eight patient records.
The findings include:
Eight patient records were reviewed for consent forms on August 11, 2015. The consents to release information forms did not document all required information in one out of eight patient records, specifically record # 2.
The findings include:
Patient # 2 was admitted to treatment on August 5, 2015. A consent form had been signed by the patient and a witness on August 10, 2015. The consent serves to release urine drug screen results, labs, medical history, and the patient's biopsychsocial evaluation; however, it does not specify who the information is to be released to or for what purpose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors received training about confidentiality and the procedure for completing releases of information on 8/13/2015 from the Director of Behavioral Health Services. DDAP Confidentiality training will be scheduled when it is available locally. The Medical Records Supervisor will monitor the charts for compliance. Any further compliance issues will be communicated to the Director of Behavioral Health Services. The facility is in compliance as of 8/13/2015. The release of information for patient #2 was rescinded on 8/13/15. |