INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Methadone monitoring conducted on November 4, 2019 through November 5, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that each counselor met the qualifications for the position in one of eight applicable personnel records reviewed.Employee # 5 was hired as counselor on November 8, 2017. The counselor did not have documentation of a qualifying degree. The file contained documentation of completion of an Associates in Applied Science; however, there was no concentration or major documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 5 will be demoted to Counselor Assistant effective 12/2/19 with direct supervision by the Program Director.
A qualified Counselor (with appropriate qualifications) will then be hired by 12/31/19 to assume the Counselor Assistant's client caseload.
The Human Resources Director is ultimately responsible to verify all new employee's Education and Credentials prior to hiring to assure the individual being hired is qualified for the position.
In order to assure future compliance, The Executive Assistant to the CEO will review all new clinical hires to assure that the proper Education and Credentials are documented in the employee's chart prior to an individual's start date. The results of this review will be reported to the Performance Improvement Committee for at least 6 months or until full compliance has been met.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to document the completion of 12 clock hours of annual training required for the Project Director for the facility's January 1, 2017 through December 31, 2017 training year.Employee # 1's employee file documented 3 hours of annual training.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will complete at least 12 clock hours of training annually in areas such as:
Fiscal policy. (ii) Administration. (iii) Program planning. (iv) Quality assurance. (v) Grantsmanship. (vi) Program licensure. (vii) Personnel management. (viii) Confidentiality. (ix) Ethics. (x) Substance abuse trends. (xi) Developmental psychology. (xii) Interaction of addiction and mental illness. (xiii) Cultural awareness. (xiv) Sexual harassment. (xv) Relapse prevention. (xvi) Disease of addiction. (xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
In order to assure continued compliance, the Program Director will achieve the total number of training hours required each year no later than 11/30/19. The Executive Assistant will be responsible to monitor the Project Director's educational hours on a quarterly basis to assure the Program Director meet the 12 hours of education by the deadline of 11/30/19.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that all heaters in the facility were permanently mounted or installed as there was a space heater discovered in counselor office 203.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heater was immediately removed from Counselor Office 203.
Staff were made aware on 11/11/19 (via memo) there is to be no space heaters used in the building.
In order to assure continued compliance, the Program Director is responsible to monitor the counselor offices on a monthly basis to assure there are no space heaters being used by the staff.
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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
The facility failed to identify, on their fire drill log, the exit route used during drills conducted during the months of March 2018 to May 2018, April 2019, June 2019 and July 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill form was revised on 11/7/19 to include "Exit Route used during Drill". Also, a memo was sent to the staff person conducting fire drills on 11/7/19 to clearly document the exit route used during the drills.
In order to assure continued compliance, the Performance Improvement Coordinator will review the monthly fire drills to assure the exit route used during drills is clearly documented on the Fire Drill form. The results of this review will be presented to the Performance Improvement Committee on a quarterly basis for at least six (6) months or until consistent compliance has been achieved.
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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
The facility failed to provide the required one hour of onsite physician time per week for every ten patients in seven weeks reviewed.The narcotic treatment physician time sheets were reviewed for the months of June, July and August. The following weeks were not in compliance:- During the week of June 2, 2019 to June 8, 2019 the patient census was 239. The facility was required to provide at least 24 physician hours. There were 21 physician hours documented. -During the week of June 30, 2019 to July 6, 2019 the patient census was 238. The facility was required to provide at least 24 physician hours. There were 21 physician hours documented. -During the week of July 14, 2019 to July 20, 2019 the patient census was 239. The facility was required to provide at least 24 physician hours. There were 13 physician hours documented. -During the week of July 21, 2019 to July 28, 2019 the patient census was 239. The facility was required to provide at least 24 physician hours. There were 19.5 physician hours documented. -During the week of August 25, 2019 to August 31, 2019 the patient census was 236. The facility was required to provide at least 24 physician hours. There were 19.5 physician hours documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program's new Narcotic Treatment Program Physician currently covers the clinic 24 hours per week.
Kensington Hospital also recently hired a full-time CRNP for Kensington Hospital that will now be available to cover for the Narcotic Treatment Physician when she is not available to cover the required number of weekly hours.
Also, an additional physician is interested in providing coverage for the Outpatient Program, as well so that the Program is covered at all times with the required number of physician hours in relation to the Program census. Both will be oriented by 12/31/19.
In order to assure continued compliance, the Program Director will be responsible to monitor the number of weekly physician hours in relation to the Program census on a weekly basis. The Program Director will report this information to the Performance Improvement Committee on a quarterly basis.
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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
The facility failed to complete a random, monthly urinalysis screening in two of seven patient records reviewed.Patient # 5 was admitted on August 1, 2018 and was discharged on July 20, 2019. There were no documented drug screen urinalyses for the month of March 2019.Patient # 6 was admitted on April 6, 2017 and was discharged on March 4, 2019. There were no documented drug screen urinalyses for the month of November 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program's laboratory (Atlantic Diagnostic Laboratory) provides an e-mail alert to the appropriate counselor in the Electronic Medical Record (EMR) when a monthly urine drug screen is due for a client.
The Program Director will re-educate the Counselors by 11/25/19 to monitor their e-mails through the EMR on a daily basis to be alerted to the fact that a client is scheduled to have a monthly urine drug screen done.
In order to assure continued compliance, the Program Director will conduct monthly monitoring of randomly selected records for each counselor to assure monthly urine drug screens are being done. The results of this monitoring will be reported to the Performance Improvement Committee on a quarterly basis for at least six (6) months or until consistent compliance has been achieved.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility failed to document bi-annual dosage reviews in one of seven patient records reviewed.Patient # 6 was admitted on April 6, 2017 and was discharged on March 4, 2019. There were no documented dosage reviews completed for the entire year of 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program's newly hired Narcotic Treatment Physician has been instructed (at a meeting held on 11/11/19 in which the deficiencies of this survey were reviewed) to review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
In order to assure continued compliance, the Program Director will monitor monthly randomly selected records to assure the Narcotic Treatment Physician is review the dosage levels at least twice a year, with each review occurring at least 2 months apart in order to determine a patient's therapeutic dosage. These results will be reported to the Performance Improvement Committee on a quarterly basis for at least six (6) months or until consistent compliance has been achieved.
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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
The facility failed to document the completion of an annual physical examination in one of seven patient records reviewed. Patient # 3 was admitted on September 20, 2016 and was active at the time of the inspection. An annual physical examination was completed September 8, 2018 with the next exam due by September 8, 2019; however, there was no documentation of an annual physical completed on file.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Physician has been made aware (at a meeting of 11/11/19) of her responsibility to document all annual physical examinations, which also includes an annual re-evaluation by the Narcotic Treatment Physician.
In order to assure continued compliance, the Program Director will review monthly randomly selected records to assure there is documentation of an annual physical exam, as well as, are-evaluation by the Narcotic Treatment Physician. The results from this review will be presented to the Performance Improvement Committee on a quarterly basis for at least six (6) months or until consistent compliance has been achieved.
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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
The facility failed to document an annual evaluation of the patient completed by the patient's counselor and reviewed, dated and signed by the medical director in one of seven client records.Patient # 3 was admitted on September 20, 2016 and was active at the time of the inspection. No annual evaluation was completed in 2018. Additionally, the annual evaluation completed in September 2019 was not reviewed, dated and signed by the medical director. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This particular client will have their annual evaluation done and dated and signed by the Medical Director by 11/25/19.
The Counselors will be re-educated by the Program Director by 11/25/19 to document an annual evaluation of each patient 's status 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.
In order to assure continued compliance, the Program Director will review monthly records by each counselor to assure the annual evaluation of each patient's status and is reviewed, dated and signed by the medical director. The results of this review will be reported to the Performance Improvement Committee on a quarterly basis for at least six (6) months or until consistent compliance has been achieved.
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