INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on April 9 and 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on May 5, 2008.
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Plan of Correction
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of six patient records, there was no documentation the facility had completed a tuberculosis Mantoux test for three of five patients reviewed, records # 1, 3 and 4.
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Plan of Correction
On admission, PPD testing will be ordered on all Behavioral Health patients. Before admission, the physician will explain to the patient that PPD testing will be given and that this is a Federal regulation. If the patient refuses the PPD or is a known positive PPD or if the patient is allergic to PPD, a chest x-ray will be done.
The Nursing staff was in-serviced on 5/9/08 by the Assistant Director of Nursing. This issue was also discussed at the May 2008 Nursing Committee meeting by the Assistant Director of Nursing. Compliance will be measured bythe Performance Improvement Coordinator by random monthly chart reviews. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on review of six patient records, the facility failed to provide an evaluative assessment of the historical data obtained that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in two of three records, # 2 and 4.
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Plan of Correction
Staff will be in-serviced by the Clinical Supervisor by 5/9/08 on providing an evaluative assessment of the historical data obtained from the patient and to include the counselor's clinical analysis of the patient's:
problems/needs,
assets/strengths,
support systems,
coping mechanisms,
negative factors,
patient's attitude toward
treatment & overall
impressions.
The Clinical Supervisor will monitor to assure the staff complies by monthly random chart reviews. |