INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12-13, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment 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 personnel records, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum.
The findings include:
Two personnel records requiring documentation of HIV/AIDS and /or TB/STD training were reviewed on August 12, 2015. One out of two records, specifically record # 5, did not contain the required documentation.
Employee # 5, a counselor, was hired on August 5, 2014. As of August 12, 2015, there was no documentation that employee # 5 completed HIV/AIDS or TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Assistant to the Director of Behavioral Health Services will track the training content for new employees. Employees are required to complete the mandatory HIV and TB-STD trainings within one year of employment in substance abuse treatment. The Administrative Assistant will monitor employee records for the completion of HIV and TB-STD trainings. Trainings will be scheduled by the Director of Behavioral Health Services based on the need of the employee. The facility has HIV and TB-STD trainings scheduled for 8/31//2015. The facility will be in compliance on 8/31/2015. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to document a treatment plan update at least every 60 days.
The findings include:
Six patient records requiring treatment plan updates were reviewed on August 12, 2015. The treatment plan updates were deficient in three out of six patient records reviewed, specifically records #1, 2, and 7.
Patient #1 was admitted on 3/20/15 and was still active at the time of inspection. An initial treatment plan was documented on 3/25/15, however there was no documentation of a treatment plan update for client # 1 throughout the duration of treatment.
Patient #2 was admitted on 4/2/15 and was still active at the time of inspection. An initial treatment plan was documented on 4/23/15, however there was no documentation of a treatment plan update for client # 2 throughout the duration of treatment.
Client #4 was admitted on 9/8/14 and was discharged on 6/2/15. A comprehensive treatment plan update was documented on 12/24/14, however there was no documentation of a treatment plan update for client # 4 throughout the remainder of treatment.
Patient #7 was admitted on 1/3/13 and was still active at the time of inspection. The last treatment plan update was documented on 4/7/15, however there was no documentation of an additional treatment plan update for client # 7 throughout the duration of treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services will provide supervision and training to the counselors/therapists on the topic of treatment planning. The Director of Behavioral Health Services reviewed the regulation regarding 60-day treatment plan updates during a staff meeting on 8/17/2015. Supervision will occur on an ongoing basis. The Lead Therapist and Director of Behavioral Health Services will conduct random weekly chart checks to ensure that the program is in compliance. The facility will be in compliance by 9/11/2015.
Patient #1 was transferred to a new counselor on 8/17/15. On 8/22/15, patient #1 was referred to Medically-Monitored Short-Tem Residential level of care. Patient #1 will have a treatment plan update upon return to Outpatient Treatment.
Patient #2 did not have Treatment Plan Updates completed by the counselor. The counselor has since resigned. The new counselor completed the Treatment Plan Update on 9/11/15.
Patient #7 was assigned to a new counselor. The new counselor completed the Treatment Plan Update on 9/11/15.
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711.93(a) LICENSURE Complete Client Record
711.93. 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 in 115.32 (relating to contents), the client record shall include the following:
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Observations
Based on the review of patient records the facility failed to ensure that a complete record that included individualized treatment plans and a follow-up attempt was documented in eight out of twelve patient records reviewed.
The findings include:
Twelve patient records were reviewed for documentation of a complete record on August 12, 2015. Five out of the twelve records reviewed required documentation of an individualized treatment plan; however four of those five records did not include documentation of an individualized treatment plan, specifically patient records #'s 1, 2, 4, and 6.
Additionally, a follow-up attempt was required in four patient records; however, four of those four patient records did not include documentation of a follow-up attempt, specifically records 9, 10, 11, and 12.
Patient # 1 was admitted on 3/20/15. As of the date of inspection, there was no documentation of an individualized treatment plan for patient # 1.
Patient # 2 was admitted on 4/21/15. As of the date of inspection, there was no documentation of an individualized treatment plan for patient # 2.
Patient # 4 was admitted on 2/25/15. As of the date of inspection, there was no documentation of an individualized treatment plan for patient # 4.
Patient # 6 was admitted on 5/7/15. As of the date of inspection, there was no documentation of an individualized treatment plan for patient # 6.
Patient #9 was admitted on 6/5/14 and discharged on 5/5/15. As of the date of inspection, there was no documentation of a follow-up attempt for patient #9.
Patient #10 was admitted on 10/1/14 and discharged on 12/24/14. As of the date of inspection, there was no documentation of a follow-up attempt for patient #10.
Patient #11 was admitted on 5/9/14 and discharged on 2/26/15. As of the date of inspection, there was no documentation of a follow-up attempt for patient #11.
Patient #12 was admitted on 12/5/06 and discharged on 3/2/15. As of the date of inspection, there was no documentation of a follow-up attempt for patient #12.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors received training about follow-up on 8/17/2015 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 to be kept as part of the patient chart. The Administrative Assistant to the Director of Behavioral Health Services will monitor the charts for compliance. Any further compliance issues will be communicated to the Director of Behavioral Health Services. The Director of Behavioral Health Services will provide supervision and training regarding follow-up as needed. The facility will be in compliance by 9/11/2015.
Patient #1 has an Initial Treatment Plan dated 3/25/15 this treatment plan was completed and signed by a counselor who resigned prior to the time of the inspection. The treatment plan was written 5 days late and signed 30 days late by the doctor. However, it was completed. Since then the facility has hired a new doctor who writes Initial Treatment Plans at the time of admission. The counselor did not complete the required Treatment Plan Updates and the patient is currently in 3B level of care. The treatment plan will be updated when he returns to the facility.
Patient #2 did not have Treatment Plan Updates completed by the counselor. The counselor has since resigned. The new counselor completed the Treatment Plan Update on 9/11/15. Patient #2 had an Initial Treatment Plan dated 4/23/15. This treatment plan was late but was there.
Patient #4 was transferred to a new counselor on 4/27/15. The new counselor completed treatment plans on 5/7/15 and 7/7/15. Both treatment plans were in the chart at the time of inspection. Both treatment plans were marked as Initial Treatment Plans in error. Both should have been Treatment Plan Updates. The previous counselor did not complete the prior required treatment plans.
Patient #6 has a Treatment Plan dated 7/15/15 this treatment plan was not in the chart at the time of the inspection.
Patient #9 Follow up for Patient #9 occurred on 5/12/15 but was not documented in the chart. Follow up was documented 9/10/15. The Counselor spoke to the patient?s cousin who informed the counselor that the patient was hospitalized with multiple brain tumors.
Patient #10 A follow up call was made by the administrative assistant on 9/10/15. The patient did not answer the phone and a message was left. This call was documented in the chart.
Patient #11 A follow up call was made by the administrative assistant to the program on 9/10/15. The counselor for Patient #11 confirmed that he is in the program. This call was documented in the chart.
Patient #12 was transferred to another program. The program faxed a letter confirming that the patient was admitted on 3/3/15 and received 95mg of methadone. The faxed letter and cover sheet were in the chart at the time of the inspection.
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