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 February 2-3, 2010 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 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on February 23, 2010.
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Plan of Correction
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to complete consents to release information according to in two of seven patient records reviewed.
The findings include:
Eight patient records were reviewed on February 2-3, 2010. Seven patient records were reviewed for completed consents to release information. The facility did not present full disclosure of what information would be released to a funding entity in two patient records, # 4 and 5.
Record # 4 had a consent to release information for the patient's funding company, but the information listed for release was restricted to the patient's presence in treatment and PCPC scores without consent to disclose the patient's diagnosis, progress or relapse history in the program.
Discussion with the facility director, nursing director and assistant nursing director confirmed the facility disclosed more than presence to funding sources and the specific funding source identified did not request PCPC scores.
This is a repeat citation from the monitoring of April 28-29, 2009
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Plan of Correction
Form has been revised to reflect the Department of Health's five (5) allowable items to disclose as of 2/4/2010.
The Clinical Supervisor will monitor proper completion of form by chart reviews for the next six (6) months. The first chart review will be within 30 days. |
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 the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected or completed within the policy-stated 48 hours of admission.
The findings include:
The policy and procedure manual was reviewed on February 2, 2010. The policy for time frame to complete the psychosocial evaluation stated it was to be completed within 48 hours of admission.
Eight patient records were reviewed on February 2-3, 2010. Four patient records required psychosocial evaluations.
Patient # 4 was admitted August 14, 2009 and was discharged August 17, 2009. An evaluation was not documented.
Patient # 7 was admitted November 13, 2009 and was discharged November 16, 2009. An evaluation was not documented.
Patients # 3 and 6 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment.
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Plan of Correction
The Psycosocial evaluations were not completed in a timely manner due to staffing turnover. However, the Clinical Supervisor will monitor the unit close and complete evaluations as needed. Chart reviews will be done for the next six (6) months to monitor for compliance with the Hospital's 48 hour policy. The first chart review will be done 3/3/2010. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to include sufficient information in the discharge summaries to determine whether they were completed within the time frame stipulated by regulation.
The findings include:
Eight patient records were reviewed on February 2-3, 2010. Five patient records required a completed discharge summary. All five records contained a completed discharge summary, but there was no date as to when the summary had been completed. Therefore, it could not be determined if it was completed within the required 7 day time frame.
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Plan of Correction
The typist will be instructed to document the date when dishcarge summary was completed.
The Performance Improvement Coordinator will monitor for compliance by conducting chart reviews for six (6) months. The first chart review will be 3/2010. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, review of administrative documentation and discussion with facility staff, the facility failed to document the attempt or completion of patient follow up contact in 4 of 5 patient records reviewed. .
The findings include:
The policy and procedure manual was reviewed on February 2, 2010. The policy for follow up of discharged patients stated it would be done within 7 days of discharge.
Eight patient records were reviewed February 2-3, 2010. Five patient records required documentation of follow up information.
Patient # 4 was discharged on August 17, 2009. There was no documentation of any follow up attempt.
Patient # 5 was discharged on October 6, 2009. There was no documentation of any follow up attempt.
Patient # 6 was discharged on January 4, 2010. There was no documentation of any follow up attempt.
Patient # 8 was discharged on December 6, 2009. There was no documentation of any follow up attempt.
Discussion with facility director after reviewing the follow up log on February 3, 2010 showed that patients who left without a referral did not receive a follow up attempt.
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Plan of Correction
The Policy has been revised to refelect follow up on all consumers within seven (7) days of discharge. Stafff was in-serviced on policy revisions by the Clinical Supervisor.
The Clinical Supervisor will conduct chart reviews for six (6) months. The first chart review was done 3/3/2010 to assure compliance. |
715.24(3) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(3) A 1-year physiologic dependence is not required for narcotic detoxification although documentation of current dependency is required.
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Observations
Based on a review of patient records, the facility failed to ensure the physician documented current dependency in three of eight patient records reviewed.
The findings include:
Eight patient records were reviewed on February 2-3, 2010. Eight patient records required documentation of the physician's determination of current dependency prior to the administration of the narcotic. Three patient records did not have the physician's documentation of determining current opiate dependency.
Patient # 2 was admitted on February 1, 2010 and the record contained a urine drug screen negative for opiates. The patient was administered 25 milligrams of methadone for detoxification starting on February 2, 2010 without the physician documenting the rationale for determining current dependency.
Patient # 3 was admitted on January 29, 2010. The patient was administered 30 milligrams of methadone for opiate detoxification without the physician documenting a determination of current dependency.
Patient # 8 was admitted on December 4, 2009. The patient was administered 20 milligrams of methadone to begin the opiate detoxification process on December 4, 2009. The physician checked off the "other" box on the physician's determination of current dependency form without specifying the "other" information.
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Plan of Correction
A memo was sent to all Attending Detox Physiciansto document the current opiate dependency before prescribing methadone.
The Performance Improvement Coordinator will monitor for compliance by conducting chart reviews for six (6) months. The first review will be done in March 2010.
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704.8(a)(1) - (5) & (b) LICENSURE Qualification Level
704.8. Qualifications for the position of counselor assistant.
(1) A Master's Degree in a human service area.
(2) A Bachelor's Degree in a human service area.
(3) Licensure in this Commonwealth as a registered nurse.
(4) An Associate's Degree in a human service area.
(5) A high school diploma or General Education Development (GED) equivalent.
(b) A counselor assistant shall also complete the training requirements in 704.11 (relating to staff development program).
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Observations
Based on the review of administrative documentation and staff interview, the facility failed to provide sufficient information to determine the qualifications of the staff hired for the counselor assistant position.
The findings include:
Two personnel files were reviewed for qualifications of the positions held or being considered for.
Employee # 1 did not have a transcript to demonstrate the concentration of her associate degree in criminal justice.
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Plan of Correction
Employee #1 has obtained her transcrips and they are part of her personnel file. The transcripts demonstrate appropriate qualifications needed for a Counselor Assistant.
In the future the Clinical Supervisor will request transcripts with all college degrees to assure the individual is qualified for the position |