INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 19, 2021 through October 20, 2021 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 Outpatient Treatment Program 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(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 the faciity-submitted Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframe for their position in one of eight personnel records reviewed.Employee # 8 was hired as a counselor on January 2, 2020 and was due to receive at least four hours of TB/STD and other health-related topics training no later than January 20, 2021; however, there was no documentation of completion of TB/STD training at the time of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee # 8 has since scheduled the required TB/STD training for 11/19/2021 from 9AM-1PM.
The CEO met with the Program's Clinical Supervisor on 10/27/2021 to review the Division of Drug & Alcohol Staffing Requirements.
All new hires to the Program will be issued their Training Needs Assessment upon hire and will obtain the required trainings within 1 year of hire.
In order to assure continued compliance, the Clinical Supervisor will be responsible and monitor the trainings on a monthly basis to assure the new hire is schedule to meet the 1 year deadline.
The results of this monitoring will be reported to the Performance Improvement Committee on a quarterly basis.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 review of the facility's August 2020 through September 2021 fire drill log, the facility failed to identify, on their fire drill log, which exit route was used during the fire drill conducted in May 2021.This is a repeat citation from the November 5, 2019 and August 19, 2020 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Environmental Services Coordinator held a meeting with the Maintenance Staff on 10/27/2021 to remind them to document the exit route used during all fire drills.
In order to assure future compliance, the Environmental Services Coordinator will review all fire drill logs presented to her by the Maintenance staff member before filing in the Fire Drill Manual.
Results of this monthly monitoring will be reported to the Safety Committee quarterly. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on an administrative review, the narcotic treatment program failed to provide the required one hour of onsite physician time per week for every ten patients in six of the sixteen weeks prior to the inspection date that was reviewed. During the week of July 11 - 17, 2021, the patient census was 178. The facility was required to provide at least 18 physician hours. There were only 12.5 physician hours documented.During the week of July 25 - 31, 2021, the patient census was 178. The facility was required to provide at least 18 physician hours. There were only 9 physician hours documented.During the week of August 1 - 7, 2021, the patient census was 179. The facility was required to provide at least 18 physician hours. There were only 8 physician hours documented.During the week of August 22 - 28, 2021, the patient census was 174. The facility was required to provide at least 18 physician hours. There were only 16 physician hours documented.During the week of August 29 - September 4, 2021, the patient census was 174. The facility was required to provide at least 18 physician hours. There were only 16 physician hours documented.During the week of September 5 - 11, 2021, the patient census was 175. The facility was required to provide at least 18 physician hours. There were only 16 physician hours documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/7/2021, a full-time physician was hired to replace the former part-time physician in order to assure the required number of hours are met at the Outpatient Treatment Program.
This new full-time physician works 4 hours per day, 5 days per week totaling 20 hours per week. Currently the Program census is 170.
The full-time physician's hours will increase according to the Program Census.
In order to assure future compliance, the Executive Assistant will now monitor the Program Physician's timesheets weekly to assure the number of physician hours are appropriate for the number of Program clients. The results of this monitoring will be reported to the Facility Director weekly. |
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 a review of patient records, the facility failed to document the completion of a random urinalysis at least monthly after their initial urinalysis in one of eleven patient records reviewed. Patient # 11 was admitted on October 3, 2016 and was discharged on September 17, 2021. The patient record did not document a urinalysis for the month of May 2021. This is a repeat citation from the May 20, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counseling staff on 10/26/2021 and 10/27/2021 to remind the Counselors of the following Division of Drug & Alcohol Program requirement: After the Program Client's initial urinalysis, a monthly random urinalysis must be done and results document in medical record by the Counselor.
In order to assure continued compliance, the Clinical Supervisor will monitor medical records to assure the Counselors are conducting monthly random urinalysis on their clients and those results are being documented in the medical record.
The results of this monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the narcotic treatment program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first two years in two of seven applicable patient records reviewed.Patient # 1 was admitted on March 24, 2021 and was still active at the time of the inspection. The record documented 2 hours and 5 minutes of psychotherapy for the month of May 2021, 2 hours of psychotherapy for the month of June 2021, 1 hour and 33 minutes for the month of July 2021, 2 hours and 3 minutes for the month of August 2021, and 1 hour and 4 minutes for the month of September 2021.Patient # 7 was admitted on June 17, 2021 and was still active at the time of inspection. The record documented 1 hour and 40 mins of psychotherapy for the month of August 2021. This is a repeat citation from the May 20, 2021 annual licensing renewal inspection.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counseling staff on 10/26/2021 and 10/27/2021 to remind the Counselors of the following: Each client is required to have an average of 2.5 hours of psychotherapy per month during the patient's first two years and it must be documented in the medical record by the Counselor.
In order to assure continued compliance, the Clinical Supervisor will review medical records monthly of those clients in their first 2 years to assure they are receiving a monthly average of 2.5 hours of psychotherapy.
The results of this monthly monitoring will be reported to the Performance Improvement Committee at their meetings quarterly. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the transfer of patient files, which is to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, in one of two applicable patient records reviewed. Patient # 4 was admitted on August 7, 2020 and was dishcarged/transferred to another narcotic treatment program on August 17, 2021. At the time of the inspection, the record did not document that the program transferred admission date, medical and psychosocial summaries, urinalysis reports or summary, exception requests, and current status of the patient to the receiving narcotic treatment program. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counselors on 10/26/2021 and 10/27/2021 to reiterate the following DDAP regulations:
Counselors must document the transfer of patient files, which is to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
In order to assure continued compliance, the Clinical Supervisor will now review monthly medical records on transferred clients to assure the transfer of patient files include the: admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests and current status of the client.
The results from this monthly monitoring of medical records will be reported to the Performance Improvement Committee on a quarterly basis. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in two of six applicable patient records reviewed.Patient # 3 was admitted on July 13, 2017 and was discharged on July 6, 2021. An annual physical examination was completed on July 11, 2019 and the next annual physical examination was due no later than July 11, 2020; however, there was no annual physical examination given by the narcotic treatment program documented in the record at the time of the inspection.Patient # 4 was admitted on August 7, 2020 and was discharged on August 17, 2021. An annual physical examination was due no later than August 7, 2021; however, there was no annual physical examination given by the narcotic treatment program documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Program Physician and the Counseling staff on 10/27/2021 to review the following DDAP regulation: All annual physical examinations must include an annual re-evaluation by the narcotic treatment physician.
In order to assure future compliance, the Clinical Supervisor will review month medical records to assure the annual physical exams include an annual re-evaluation by the Program Physician.
The results of this monthly review will be presented to the Performance Improvement Committee quarterly to assure the annual physicals include the annual re-evaluation by the Program Physician.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director, in one of five applicable patient records reviewed. Patient # 4 was admitted on August 7, 2020 and was discharged on August 17, 2021. An annual evaluation was due no later than August 7, 2021; however, there was no annual evaluation documented in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Certified Registered Nurse Practitioner (CRNP) was hired on 9/9/2021 to only perform annual evaluations for the Outpatient Treatment Program on a weekly basis.
The Clinical Supervisor met with the Counseling staff on 9/8/2021 to inform them to have their clients scheduled with the CRNP to have their annual physical done a week prior to their anniversary date.
In order to assure continued compliance, the Clinical Supervisor will review medical records on a monthly basis to assure the annual physicals are being done prior to the client's anniversary date.
The findings from this monthly review will be presented to the Performance Improvement Committee quarterly.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on an administrative review and a review of patient records, the narcotic treatment program failed to file a written unusual incident report with the Department within 48 hours following a compliant of patient abuse (physical, verbal, sexual and emotional). A reviewed patient record indicated that on June 30, 2021, a physical assault of a patient on facility premise occurred; however, at the time of the inspection, there was no documentation of the physical assault being reported to the Department. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counseling staff on 10/27/2021 to reiterate the fact that a written unusual incident report must be filed within 48 hours to the Department following a complaint of patient abuse such as: physical abuse, verbal abuse, sexual abuse or emotional abuse.
In order to assure continued compliance, the Counselors will submit a written incident report to the Department within 48 hours of any complaint of patient abuse.
The Clinical Supervisor will monitor all incident reports to assure the reports of patient abuse have been reported to the Department within 48 hours of the incident.
Results of this monitoring will be reported to the Patient Safety Committee meeting at their monthly meeting.
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711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. 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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of eleven client records reviewed.Client # 4 was admitted on August 7, 2020 and was discharged on August 17, 2021. A release of information form was signed and dated by the client and witness on August 13, 2021; however, the form did not document the name of the person, agency or organization to whom the disclosure was to be made. This is a repeat citation from the May 20, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counseling Staff on 10/27/2021 to in-service the counselors that they must document the name of the person, agency and/ organization to whom a disclosure was to be made to on release of information forms.
In order to assure continued compliance, the Clinical Supervisor will review medical records on a monthly basis to assure the following information is documented on the Release of Information form: name of the person, agency and organization to whom the disclosure is being made to.
The results of this monthly monitoring will then be presented to the Performance Improvement Committee on a quarterly basis. |
711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. 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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in two of eleven client records reviewed. Client # 4 was admitted on August 7, 2020 and was discharged on August 17, 2021. There was a blank release of information form was signed and dated by the client and witness on August 13, 2021; however, the form did not document the specific information to be disclosed.Client #9 was admitted on May 25, 2021 and still active at the time of inspection. There was a consent to release information form to an emergency contact; however, the form did not document the specific information to be disclosed.This is a repeat citation from the May 20, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the Counseling Staff on 10/27/2021 to in-service them on the specific information to be released on the Consent to Release Form.
On 11/8/2021, Client #4's Counselor completed the Release of Information form with the specific information to be disclosed.
In order to assure continued compliance, the Clinical Supervisor will monitor medical records on a monthly basis to assure the specific information to be released on the Consent to Release form is thoroughly documented by the Counselor.
The results of this monthly monitoring will be reported to the Hospital's Performance Improvement Committee at their quarterly meetings. |
711.93(c)(2)(iii) LICENSURE Purpose of Disclosure
711.93. 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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in one of eleven client records reviewed. Client # 4 was admitted on August 7, 2020 and was discharged on August 17, 2021. There was a blank release of information form signed and dated by the client and witness on August 13, 2021; however, the form did not document the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor in-serviced the Counselors on 10/27/2021 to assure they document the purpose of disclosure on the Consent to Release Information forms.
In order to assure future compliance, the Clinical Supervisor will review medical records on a monthly basis to assure the counselors are documenting the purpose of the disclosure on the Consent to Release Information form.
The results of the monthly monitoring will then be presented to the Performance Improvement Committee at their quarterly meetings.
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711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
711.93. 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 the 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 consent to release information forms in one of eleven client records reviewed.Client #9 was admitted on May 25, 2021 and still active at the time of inspection. There was a consent to release information form, signed and dated by the client, to an emergency contact; however, the consent form did not document the dated signature of the client.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor in-serviced the Counseling staff on 10/27/2021 to reiterate they must document the dated signature of the client on the Consent to Release Information form.
On 11/8/2021, Client #9's Counselor completed the date of the client's signature on the consent form.
To assure continued compliance, the Clinical Supervisor will conduct monthly chart reviews to assure Counselors are documenting the dated signature of the client on the Consent to Release Information form.
Results of this monthly monitoring will be forwarded to the Performance Improvement Committee on a quarterly basis. |
711.93(c)(2)(v) LICENSURE Signature of Witness
711.93. 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:
(v) The dated signature of a witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on consent to release information forms in one of eleven client records reviewed.Client #9 was admitted on May 25, 2021 and still active at the time of inspection. There was a consent to release information form to an emergency contact, signed and dated by the client; however, the consent form did not document the dated signature of a witness.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met on 10/27/2021 to in-service the Counseling staff to document the dated signature of a witness on the Consent to Release Information form.
On 11/8/2021, Client #9's Counselor had the dated signature of a witness completed on the Consent to Release Information form.
The Clinical Supervisor will review medical records monthly to assure the Counselors are documenting the dated signature of a witness on the Consent to Release Information form to assure continued compliance.
The results of the monthly monitoring will be submitted to the Performance Improvement Committee on a quarterly basis. |
711.94(b) LICENSURE Display Hours of Operation
711.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection and a conversation with facility staff, the facility failed to conspicously display the project's hours of operation to the general public. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Hospital Administration ordered a professional sign on 10/29/2021 to be posted on the window of the Narcotic Treatment Program to conspicously display the project's hours of operation to the general public.
The scheduled date of arrival of the sign is 11/11/2021.
Upon receipt of the sign, the Maintenance staff will post the sign on the window of the Narcotic Treatment Program. |
711.94(c) LICENSURE Display Emerg. Telephone Number
711.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection and a conversation with facility staff, the facility failed to conspicuously display an emergency telephone number to the general public.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Hospital Administration ordered a professional sign on 10/29/2021 to be posted on the Narcotic Treatment Program window to conspicuously display the emergency telephone number to the general public.
The anticipated delivery of the sign is 11/11/2021.
Upon receipt of the sign, the Maintenance Staff will post the sign on the Narcotic Treatment Program's window.
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