INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and a narcotic monitoring conducted on September 20-21, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital was found to be not 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of presubmission material and an interview with the facility director, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The facility training year runs from January 1 thru December 31 and the training year reviewed was 2015. The facility failed to submit or subsequently provide an overall training plan.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Chief Executive Officer of Kensington Hospital will ensure that an overall training plan is completed for the project. The Chief Executive Officer will complete the overall training plan for the project. The overall training plan will be completed at the beginning of the training calendar. Compliance with the overall training plan will be monitored by the Administrative Assistant to the CEO. The program will be in compliance by 11/4/16. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for one of four personnel records reviewed.
Employee #4 was hired on 9/21/2015 and was required to complete TB/STD and HIV/AIDS training within one year. As of the date of the inspection none of the above trainings were completed.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Director of Behavioral Health Services will include DDAP approved HIV/AIDS and TB/STD training on the training plans for new counselors and counselor assistants. Trainings will be scheduled by the counselor/counselor assistant based on the need of the counselor/counselor assistant. Successful completion of HIV/AIDS and TB/STD training will be evaluated during performance evaluations. Compliance with training will be monitored by the administrative assistant. The facility will be in compliance by 2/28/2017, the end of the 2016 training year.
Employee #4 will be scheduled for the next available HIV/AIDS training and TB/STD training in Philadelphia. The remaining trainings in Philadelphia are full for the remainder of 2016. Employee #4 will be scheduled for the next available trainings at BHTEN. The facility will be in compliance by 2/28/2017. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of two applicable personnel record, as required by regulation.
Employee # 3 was hired on September 28, 2016. Fire extinguisher training was due to be completed at the time of hire, however the facility did not document the date of completion of fire extinguisher training.
Employee # 4 was hired on September 21, 2016. Fire extinguisher training was due to be completed at the time of hire, however the facility did not document the date of completion of fire extinguisher training.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All Kensington Hospital employees receive training in the use of fire extinguishers. Employees #3 and #4 received the training but the training was documented incorrectly. The omission of the date was brought to the attention of the project administrative assistant on 9/20/16. The project administrative assistant will monitor the training forms for compliance. The facility is in compliance as of 10/18/16. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs and an interview with the facility staff, the facility failed to document the exit route used during monthly fire drills, as required by regulation.
Monthly fire drill logs from October 2015 thru August 2016 were submitted by the facility and did not indicate the exit route.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The fire drill logs were amended to include the exit route used during the monthly fire drill. The amended fire drill log went into use on 10/3/16. The fire drill log will be monitored by the Director of Environmental Services. The facility is in compliance as of 10/3/16. |
715.5(1-5) STANDARD Patient capacity
The Department may increase or decrease the number of patients a narcotic treatment program may treat. The Department may raise the patient capacity, upon the written request of the narcotic treatment program, based upon the Department 's review of the narcotic treatment program. The factors the Department will consider include:
(1) Safety. Considerations include dispensing time, internal patient flow and external traffic patterns.
(2) Physical facility. Considerations include the number and size of counseling offices, waiting areas, restrooms, and dispensing and nursing windows.
(3) Staff size and composition. Considerations include the number of narcotic treatment physicians, dispensing and counseling staff.
(4) Ability to provide required services. Considerations include compliance with licensing and narcotic treatment program regulations as determined during licensing, monitoring and special visits to the narcotic treatment program.
(5) Availability and accessibility of service. Considerations include the location of the narcotic treatment program and the hours of operation.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report (SRFSR) and a conversation with the facility staff, the facility failed to maintain a census at or below the licensed capacity of 10.
During the months of August 29, 2016 through September 2, 2016 the facility's capacity as documented on the SRFSR was 14.
The information was reviewed with facility during the licensing inspection.
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Plan of Correction
On 9/9/16, the facility received approval from DDAP to flex 15 of the 28 Inpatient Hospital Detoxification beds to use as Inpatient Non-Hospital Detoxification beds. Compliance with flex beds will be monitored by the Director of Behavioral Health Services. The facility is in compliance as of 9/9/16. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records the facility failed to document verification of patient age in client records #2, 3, and 5.
#2 was admitted on 9/20/2016 and was still an active client at the time of the inspection.
#3 was admitted on 9/16/2016 and was discharged on 9/21/2016.
#5 was admitted on 9/17/2016 and was still an active client at the time of the inspection.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake staff were trained on 10/18/16 to check a patient's identification to verify that the patient is 18 years of age or older. The patient's identification card is scanned and stored in the EMR. A printout of the identification will be available for inspection by DDAP. Age verification will be monitored by the Director of Behavioral Health Services. The facility will be in compliance on 10/19/16.
Patient #2 was discharged on 9/25/2016.
Patient #3 was discharged on 9/21/2016.
Patient #5 was discharged on 9/22/2016. |
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 client records the facility failed to document an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in client records #1, 2, 3, 4 and 5.
#1 was admitted on 9/19/2016, received their initial dose on 9/19/2016 and was still an active client at the time of the inspection.
#2 was admitted on 9/20/2016, received their initial dose on 9/21/2016 and was still an active client at the time of the inspection.
#3 was admitted on 9/16/2016, received their initial dose on 9/16/2016 and was discharged on 9/21/2016.
#4 was admitted on 9/19/2016, received their initial dose on 9/20/2016 and was still an active client at the time of the inspection.
#5 was admitted on 9/17/2016, received their initial dose on 9/17/2016 and was still an active client at the time of the inspection.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Chart reviews for patient #1, #2, #3, #4 and #5 revealed that the Informed Consent form for use of a narcotic agent was signed by the patient and Intake Worker at the time of admission. The facility failed to provide a printed copy of the form from the EMR to the inspector. The Director of Behavioral Health Services will ensure that the proper documentation is printed during the next inspection. The program is in compliance as of 10/18/16. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of client records the facility failed to document a a photograph of each patient which includes the patient 's name and birth date in client records #2, 3 and 5.
#2 was admitted on 9/20/2016 and was still an active client at the time of the inspection.
#3 was admitted on 9/16/2016 and was discharged on 9/21/2016.
#5 was admitted on 9/17/2016 and was still an active client at the time of the inspection.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Intake staff were trained on 10/18/16 to check a patient's identification to verify the patient's identity by the picture on the ID. The patient's identification card is scanned and stored in the EMR. A printout of the identification will be available for inspection by DDAP. Picture verification will be monitored by the Director of Behavioral Health Services. The facility will be in compliance on 10/19/16.
Patient #2 was discharged on 9/25/2016.
Patient #3 was discharged on 9/21/2016.
Patient #5 was discharged on 9/22/2016. |
717.18(a)(2) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(2) Employment services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for the provision of vocational services as required by regulation.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Director of Behavioral Health Services will connect with local employment services and develop referral agreements between Kensington Hospital and the employment service. These agreements will updated every two years. Compliance with referral agreements will be monitored by the facility Administrative Assistant. The facility will be in compliance by 12/30/16. |
715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for the provision of adult educational services as required by regulation.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Director of Behavioral Health Services will connect with local adult educational services and develop referral agreements between Kensington Hospital and the employment service. These agreements will updated every two years. Compliance with referral agreements will be monitored by the facility Administrative Assistant. The facility will be in compliance by 12/30/16. |
715.18(b) LICENSURE Rehabilitative services
(b) A patient shall also have the opportunity to access legal services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for the provision of legal services as required by regulation.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Director of Behavioral Health Services will connect with local legal services and develop referral agreements between Kensington Hospital and the employment service. These agreements will updated every two years. Compliance with referral agreements will be monitored by the facility Administrative Assistant. The facility will be in compliance by 12/30/16. |
715.24(4)(iii) 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:
(4) Minimum requirements for short-term narcotic detoxification treatment are as follows:
(iii) The narcotic treatment program shall develop a treatment plan. The patient's counselor shall monitor the patient's progress toward the goal of short-term narcotic detoxification and possible drug-free treatment referral.
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Observations
Based on a review of client records the facility failed to document a treatment plan in client records #1, 2, 3, and 5.
#1 was admitted on 9/19/2016 and was still an active client at the time of the inspection.
#2 was admitted on 9/20/2016 and was still an active client at the time of the inspection.
#3 was admitted on 9/16/2016 and was discharged on 9/21/2016.
#5 was admitted on 9/17/2016 and was still an active client at the time of the inspection.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Chart reviews for patient #1, #2, #3, #4 and #5 revealed that the Treatment Plans were in the electric record. The facility failed to provide a printed copy of the treatment plans from the EMR to the inspector. The Director of Behavioral Health Services will ensure that the proper documentation is printed during the next inspection. The program is in compliance as of 10/18/16. |
711.61(c)(3)(iii) LICENSURE Personal History
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records the facility failed to document a personal history in client records #1, 2 and 4.
#1 was admitted on 9/19/2016 and was still an active client at the time of the inspection.
#2 was admitted on 9/20/2016 and was still an active client at the time of the inspection.
#4 was admitted on 9/19/2016 and was still an active client at the time of the inspection.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services will revise the facility intake procedure to include personal history at the time of admission. The Director of Behavioral Health Services is attending training on building electronic forms in the EMR from 11/14/16 through 11/17/16. The Director of Behavioral Health Services will build a user-friendly tool to document personal history. The Director of Behavioral Health Services will monitor the electronic record for compliance with personal histories. The facility will be in compliance by 11/28/16.
Patient #1 was discharged on 9/24/2016.
Patient #2 was discharged on 9/25/2016.
Patient #4 was discharged on 9/24/2016.
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711.61(c)(4) LICENSURE Consent to Treatment
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records the facility failed to document a consent to treatment in client records #1, 2, 3, 4 and 5.
#1 was admitted on 9/19/2016, received their initial dose on 9/19/2016 and was still an active client at the time of the inspection.
#2 was admitted on 9/20/2016, received their initial dose on 9/21/2016 and was still an active client at the time of the inspection.
#3 was admitted on 9/16/2016, received their initial dose on 9/16/2016 and was discharged on 9/21/2016.
#4 was admitted on 9/19/2016, received their initial dose on 9/20/2016 and was still an active client at the time of the inspection.
#5 was admitted on 9/17/2016, received their initial dose on 9/17/2016 and was still an active client at the time of the inspection.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Chart reviews for patient #1, #2, #3, and #4 revealed that the Consent to Treatment was signed by the patient and Intake Worker at the time of admission. The facility failed to provide a printed copy of the form from the EMR to the inspector. The Director of Behavioral Health Services will ensure that the proper documentation is printed during the next inspection. The facility is is compliance as of 10/18/16. Patient #5 did not have the Consent to Treatment. The Intake Worker responsible received training from another Intake Worker on 11/1/16. The Director of Behavioral Health Services reviewed a sample of the intake worker's charts. The charts are now in compliance. The Director of Behavioral Health Services will monitor the electronic record for compliance with Consent to Treatment. The facility is in compliance as of 11/18/16.
Patient #1 was discharged on 9/24/2016.
Patient #2 was discharged on 9/25/2016.
Patient #3 was discharged on 9/21/2016.
Patient #4 was discharged on 9/24/2016.
Patient #5 was discharged on 9/22/2016.
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711.61(c)(6) LICENSURE Psychosocial Evaluation
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records the facility failed to document a psychosocial evaluation in client records #3, 5, and 10. Additionally, client record #9 contained an incomplete psychosocial evaluation.
#3 was admitted on 9/16/2016 and was discharged on 9/21/2016.
#5 was admitted on 9/17/2016 and was still an active client at the time of the inspection.
#9 was admitted on 2/3/2016 and was discharged on 2/4/2016. A psychosocial evaluation was documented in the record however the clinical impression section was incomplete.
#10 was admitted on 12/22/2015 and was discharged on 12/27/2015.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services will revise the facility intake procedure to include psychosocial evaluation at the time of admission. The Director of Behavioral Health Services is attending training on building electronic forms in the EMR from 11/14/16 through 11/17/16. The Director of Behavioral Health Services will build a user-friendly tool to document psychosocial evaluation. The Director of Behavioral Health Services will monitor the electronic record for compliance with psychosocial evaluation completion. The facility will be in compliance by 11/28/16.
Patient #3 was discharged on 9/21/2016.
Patient #5 was discharged on 9/22/2016.
Patient #10 was discharged on 12/27/2015.
Patient #9 was discharged on 2/4/2016. |
711.62(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records conducted on September 21, 2016, the facility failed to provide a complete client record in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The record of service were missing in client records #1, 2, 3, 4, and 5.
Additionally, there were no follow-up information documented in client records #6, 7, 8, 9 and 10.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services is attending training on building electronic forms in the EMR from 11/14/16 through 11/17/16. The Director of Behavioral Health Services will build a record of service tool in the EMR. The Director of Behavioral Health Services will train staff on the record of service once the tool is built. The Director of Behavioral Health Services will monitor the electronic record for compliance with the record of service. The facility will be in compliance by 11/28/16.
Counselors received training about follow-up on 10/18/16 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 part of the patient chart. The Director of Behavioral Health Services will monitor the charts for compliance. The Director of Behavioral Health Services will provide supervision and training regarding follow-up as needed. The Director of Behavioral Health Services will monitor the electronic record compliance with follow-up. The facility will be in compliance by 10/25/16.
Patient #1 was discharged on 9/24/2016.
Patient #2 was discharged on 9/25/2016.
Patient #3 was discharged on 9/21/2016.
Patient #4 was discharged on 9/24/2016.
Patient #5 was discharged on 9/22/2016.
Follow up was conducted for patients #6, 7, 8, 9 and 10 on 9/26/2016. |
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 document an informed and voluntary consent in client records, 1, 2, 3, 4, 5, 6, 7, 8 and 10.
Client #1 was admitted on 9/19/2016 and was still an active client at the time of the inspection. The facility failed to document what was being released in a consent to release form dated 9/16/16 for the client's funding source.
Client #2 was admitted on 9/20/2016 and was still an active client at the time of the inspection. No consent to the funding source was documented in the record.
Client #3 was admitted on 9/16/2016 and was discharged on 9/21/2016. No consent to the funding source was documented in the record.
Client #4 was admitted on 9/19/2016 and was still an active client at the time of the inspection. No consent to the funding source was documented in the record.
Client #5 was admitted on 9/17/2016 and was still an active client at the time of the inspection. No consent to the funding source was documented in the record.
Client #6 was admitted on 4/6/2016 and was discharged on 4/11/2016. A progress noted entry dated 4/11/2016 indicated that the patient was being transferred to another provider and in a later entry indicated patient was picked up by treatment provider, however, no consent to release for the treatment provider was documented.
Client #7 was admitted on 10/15/2015 and was discharged on 10/20/2015. The facility failed to document the effective date or the date the consent would expire for the consent dated 10/16/15 for a family member.
Client #8 was admitted on 12/22/2015 and was discharged on 12/27/2015. A progress noted entry dated 12/27/2015 indicates patient was being transferred to another provider and a later entry indicated patient was picked up by the treatment provider, however, no consent to release for the treatment provider was documented.
Client #10 was admitted on 9/16/2016 and was discharged on 9/21/2016. No consent to the funding source was documented in the record.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Chart reviews for patient #1, #2, #3, #4 and #5 revealed that the Release of Information Consent form to release information to the funder was signed by the patient and Intake Worker at the time of admission. The facility failed to provide a printed copy of the form from the EMR to the inspector. The Director of Behavioral Health Services will ensure that the proper documentation is printed during the next inspection. The program is in compliance as of 10/18/16.
Counselors received training about confidentiality and the procedure for completing releases of information on 10/18/16 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 will be in compliance as of 10/19/16.
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