INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2013 to November 22, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center 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 records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of five personnel records reviewed.
The findings included:
Eleven personnel records were reviewed on November 20, 2013. Eight personnel records were counselors and five were reviewed for annual training hours. One personnel record failed to document the 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 6.
The Project/Facility Director confirmed that the counselor did not have the 25 clock hours of training for the prior training year.
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Plan of Correction
The clinical management team will receive quarterly training reports from the HR department. The responsible supervisor will then meet with clinicians to ensure that all required training hours are completed. This leadership data will be reviewed quarterly by the clinical leadership at the HR dashboard. The facility will be in full compliance by 1/1/14 when all training hours are due to be completed. |
709.123(c)(2) LICENSURE Record of Service
709.123. Treatment and rehabilitation.
(c) Client records. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Record of services provided.
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Observations
Based on the review of patient records, the facility failed to document records of services that included clinical activity in two of two records.
The findings included:
Three patient records were reviewed on November 21, 2013. Two records were reviewed for a complete client record. The two records, # 5 and 6, contained service logs that did not include the services for the clinical sessions.
The findings were reviewed and confirmed by Project/Facility Director.
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Plan of Correction
The assigned social workers/primary therapist will complete service logs for al clinical sessions. The charts will be audited on a bi-weekly basis for a period of 90 days by the compliance department and results will be reported to both the chemical dependency and hospital dashboards. The facility will be in full compliance by 12/23/2013. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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 the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in thirteen of thirteen records. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one of thirteen records reviewed.
The findings included:
Twenty patient records were reviewed during the onsite review. Four records were from the inpatient non-hospital detoxification treatment activity, three records were from the psychiatric hospital treatment activity, and thirteen records were reviewed from the inpatient non-hospital drug-free treatment activity. Thirteen records were reviewed for consents to release information, # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 14. The facility also failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in record, # 1.
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers,
insurance company health or hospital plan or governmental officials, under subsection
(a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or
alcohol abuse and the frequency of such relapse.
A review of the thirteen patient records revealed use of Internet insurance eligibility websites for verification of coverage. The records did not contain documentation of consents to release information to permit disclosure of client identifying information to the multiple websites used.
A review of patient record # 1 revealed consents to release information, dated October 25, 2013, that noted the description of services provided was to be released to the primary care physician to insure continuity of care, an emergency contact, and insurance providers to provide third party payors with sufficient information to insure payment for services provided. The information to be released did not correspond to the purpose identified. A consent to release information, dated October 28, 2013, to another treatment provider noted the purpose as intensive outpatient therapist. A consent to release information, dated October 28, 2013, to a physician noted the patient's presence in treatment would be disclosed for the purpose to insure continuity of care. The information to be released did not correspond to the purpose identified. A consent to release information, dated October 25, 2013, to a legal entity stated the purpose was to allow the criminal justice system to monitor the patient's presence and progress in treatment. This purpose exceeds that permitted by Pa Code 255.5.
A review of patient record # 2 revealed a consent to release information, dated October 24, 2013, with a purpose that was illegible, and the patient was not offered a copy.
A review of patient record # 5 revealed a consent to release information, dated November 9, 2013, for an emergency contact that identified the purpose as continuity of care. The information to be released did not correspond to the purpose identified. A consent to release information, dated November 9, 2013, for a verification website did not include the information to be disclosed, the purpose for the disclosure nor was the patient offered a copy.
A review of patient record # 6 revealed consents to release information, dated November 10, 2013, that identified the information to be disclosed as presence in treatment/admission and discharged dates for an emergency contact with a purpose for emergency contact and for a physician with a purpose of physician. The information to be released did not correspond to the purpose identified.
A review of patient record # 12 revealed a consent to release information dated November 7, 2013, that was documented with check marks between the boxes, not clearly providing informed consent to the patient regarding to whom the information would be released.
A review of patient record # 13 revealed multiple consents dated November 6, 2013. One consent to release information for an emergency contact had no information identified. A consent to release information to an insurance website contained check marks between boxes, not clearly providing informed consent to the patient regarding the information to be disclosed and did not identify the purpose for the disclosure. Two consents to release information to family members identified the purpose for the disclosure as per the patient's request.
The findings regarding the consents to release information were reviewed and confirmed by the project/facility director.
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Plan of Correction
The admissions management team along with clinical management will meet with all appropriate staff to provide training on consents. Employees will be trained on both the purpose of consents as well as how to fully and appropriately complete all consents. The admissions department specifically will begin to obtain consents for all internet insurance eligibility websites. Charts will be reviewed in our bi-weekly audit schedule by the compliance department for a period of 90 days. The results of all audits will be reviewed by management in both the chemical dependency and hospital dashboard. The facility will be in full compliance by 12/2/2013. |
709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of patient records, the facility failed to document a detailed history that included medical, drug or alcohol history, and personal history in three of four records reviewed.
The findings included:
Four patient records were reviewed on November 20, 2013. The facility failed to document a drug and alcohol history that included the patient's patterns of use and a detailed personal history in records # 1, 2 and 3.
Patient # 1 was admitted on October 25, 2013. The drug and alcohol history did not include the patient's patterns of use. The record failed to include a detailed educational and sexual history.
Patient # 2 was admitted on October 23, 2013. The drug and alcohol history did not include the patient's patterns of use. The record failed to include a detailed legal, employment, educational and sexual history.
Patient # 3 was admitted on November 12, 2013. The drug and alcohol history did not include the patient's patterns of use.
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Plan of Correction
The clinical management team will provide both group and individual training to all clinicians in reference to obtaining a full and detailed medical history. A sample of charts will be monitored by clinical leadership on a bi-weekly basis to ensure that complete documentation is being done. The management team will review results for a 90 day period in the chemical dependency dashboard and full compliance will be achieved by 12/11/13. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based upon a review of patient records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors in two of four records.
The findings included:
Four patient records were reviewed on November 20, 2013. Two records lacked documentation of a psychosocial evaluation that included an assessment of the patient's problems and needs, assets and strengths, support systems, coping mechanisms and/or negative factors, specifically records # 1 and 2.
Patient # 1 was admitted on October 25, 2013. The psychosocial evaluation failed to include a clinical assessment of the patient's coping mechanisms.
Patient # 2 was admitted on October 23, 2013. The psychosocial evaluation failed to include a clinical assessment of the patient's problems and needs, assets and strengths, support systems, coping mechanisms, and negative factors. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for the required components.
This is a repeat citation from the November 26-29, 2012 licensing inspection and the follow up of May 14, 2013.
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Plan of Correction
The clinical management team will provide both group and individual training to all clinicians on the importance of completing a full clinical assessment and evaluation. The clinicians will be provided with concrete examples of appropriate psychosocials as part of the training process. A sample of charts will be audited by clinical leadership on a bi-weekly basis for a period of 90 days that will be reviewed in chemical dependency dashboard. Full compliance will be achieved by 12/11/13. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of patient records, the facility failed to document a face to face determination prior to the initial dose in one of two records reviewed.
The findings included:
Two patient records were reviewed on November 20, 2013.
The Medication log in patient record # 2 noted the patient was medicated with Suboxone, a narcotic agent, at 0900. The documentation by the physician was dated and signed at 0945 for the face to face determination, the medication dose and the consult with the physician who completed the physical. The face to face, dose and consult were documented after the time documented for the administration of the medication.
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Plan of Correction
All clients will be met with prior to the administration of a narcotic agent. The nurses will be provided with supervision by the DON and/or ADON on the importance of writing the appropriate time on the medication form to ensure that the specific time of administration is documented accurately. The nursing management team as well as the compliance department will do weekly chart checks to ensure compliance for a period of 90 days and results will be reported to the appropriate dashboard meetings. The facility will be in full compliance by 12/16/2013. |
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, the facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings included:
Two patient records were reviewed on November 20, 2013. Both patient records included non-CLIA and non-Department of Health approved dip stick for assessment.
This is a repeat deficiency from the May 15, 2013, on-site review.
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Plan of Correction
Each patient upon admission will receive a Urine Drug Screen (rapid) conducted by an Admission's Representative. Each specimen will then be forwarded to a CLIA and Department of Health approved laboratory. The complete drug screen will be reviewed by the Narcotic Treatment Physician prior to the administration of a narcotic agent to the patient. This process will go into effect immediately. The Admission Department Manager will in-service all staff on this process and conduct random patient admit record reviews to audit compliance for a period of 90 days. Findings will be reported immediately to the Executive Director when an action needs to take place. Findings of the audits otherwise will be reported monthly to the clinical oversight team known as the Chemical Dependency Dashboard. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of patient records, the facility failed to document a detailed history that included medical, drug or alcohol history, and personal history in three of seven records reviewed.
The findings included:
Thirteen patient records were reviewed on November 21, 2013 and November 22, 2013. Seven patient records were reviewed for detailed histories. The facility failed to document a drug and alcohol history that included the patient's patterns of use, prior treatment, and perception of use as well as a detailed personal history in records # 8, 12 and 13.
Patient # 8 was admitted on October 10, 2013. The drug and alcohol history did not include the patient's patterns of use.
Patient # 12 was admitted on November 7, 2013. The drug and alcohol history did not include the patient's patterns of use, prior treatment, and perception of use. The record failed to include a detailed legal, educational and recreational history.
Patient # 13 was admitted on November 6, 2013. The drug and alcohol history did not include the patient's patterns of use. The record failed to include a detailed legal, employment, educational and sexual history.
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Plan of Correction
The clinical management team has constructed a new assessment form and they will provide both group and individual training to all clinicians. A sample of charts will be audited by clinical leadership on a bi-weekly basis to ensure compliance with documentation of the full medical history including but not limited to, patterns of use, prior treatment, perception of use, legal employment and educational history. The management team will review results for a period of 90 days at chemical dependency dashboard and full compliance will be achieved by 1/20/2014. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of patient records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the patient's assets/strengths, support systems, and negative factors in four of seven records.
The findings included:
Thirteen patient records were reviewed on November 21, 2013 and November 22, 2013. Seven records were reviewed for psychosocial evaluations. Four records lacked documentation of a psychosocial evaluation that included an assessment of the patient's assets and strengths, support systems, and negative factors, specifically records # 8, 9, 12 and 13.
Patient # 8 was admitted on October 10, 2013. The psychosocial evaluation failed to include a clinical assessment of the patient's support systems.
Patient # 9 was admitted on October 25, 2013. The psychosocial evaluation failed to include a clinical assessment of the patient's support systems.
Patient # 12 was admitted on November 7, 2013. The psychosocial evaluation failed to include a clinical assessment of the patient's assets and strengths and support systems
Patient # 13 was admitted on November 6, 2013. The psychosocial evaluation failed to include a clinical assessment of the patient's assets and strengths and negative factors.
This is a repeat citation from the November 26-29, 2012 licensing inspection and the follow up of May 14, 2013.
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Plan of Correction
The clinical management team has constructed a new psychosocial assessment form and they will provide both group and individual training to all clinicians on how to appropriately complete this document. A sample of charts will be audited on a bi-weekly basis by clinical leadership to ensure that a full psychosocial history is completed including but not limited to, the patients assets/strengths, support systems and negative factors. The results of these audits will be shared in the chemical dependency dashboard for a period of 90 days and full compliance will be met by 1/20/2014. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of patient records, the facility failed to provide counseling services as stated on the treatment plan in two of seven patient records.
The findings included:
Seven patient records were reviewed on November 21, 2013 and November 22, 2013. The facility failed to document counseling services provided according to the treatment plan in patient records # 10, and 12.
Patient record # 10 contained a treatment plan dated November 14, 2013, that identified individual counseling services to be provided weekly and group sessions three times per week. The facility documented an individual and group session on November 14, 2013, an individual and group session on November 19, 2013, and a group session on November 20, 2013.
Patient record # 12 contained a treatment plan dated November 8, 2013, that identified individual counseling services to be provided weekly and group sessions three times per week. The facility documented the last individual session on November 11, 2013, that included the patient's treatment court case manager.
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Plan of Correction
The clinicians will ensure that counseling services are provided according to the needs identified in the treatment plan. The clinicians will be provided with training by clinical management on what should occur if a client is unable to attend a scheduled session to ensure proper documentation and follow up. This will be reviewed by chart audits completed by clinical leadership and the compliance department for a period of 90 days. Results will be reported in the chemical dependency and hospital dashboard. Full compliance will be achieved by 12/4/13. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of patient records, the facility failed to document a complete patient record that included discharge summary in four of six records reviewed
The findings included:
Thirteen patient records were reviewed on November 21, 2013 and November 22, 2013. Six patient records were reviewed for aftercare plans, discharge summaries and follow up. Four patient record discharge summaries did not include all of the required components, # 15, 16, 18 and 20.
Patient # 15 was admitted on May 17, 2013, and discharged on July 25, 2013. The record contained a discharge summary dated July 25, 2013 that did not include the reasons for treatment and the response to treatment.
Patient # 16 was admitted on September 4, 2013, and discharged on October 11, 2013. The record contained a discharge summary dated October 11, 2013 that did not include a response to treatment.
Patient # 18 was admitted on May 16, 2013, and discharged on July 1, 2013. The record contained a discharge summary that was originally dated June 19, 2013. The only change was the cross out of the date; the summary was not updated from the original date. The patient and staff signed the discharge summary on June 19, 2013. The discharge summary was documented prior to discharge.
Patient # 20 was admitted on June 11, 2013, and discharged on August 1, 2013. The record contained a discharge summary dated July 26, 2013 that did not include the reasons for treatment and the response to treatment. Additionally, the discharge summary was documented prior to discharge.
This is a repeat citation from the November 26-29, 2012 licensing inspection.
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Plan of Correction
The clinical team will be provided with group and individual training in reference to the proper completion of discharge summaries. The clinicians will be provided with examples of a properly completed discharge summary. The discharge summary will be reviewed on a bi-weekly basis by both clinical leadership and medical records for a period of 90-days. Full compliance will be achieved by 12/18/2013. |