This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on June 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital 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 and a plan of correction is due on June 24, 2010.
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Plan of Correction
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Observations
Based on the review of patient records and a discussion with the facility director, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected.
The findings include:
Five patient records were reviewed on June 2, 2010. Five patient records were reviewed for psychosocial evaluations. Patient records # 1, 2, 3, 4, and 5 contained a repeat of the historical data collected, patient reported commentary and no clinical assessment.
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Plan of Correction
Current staff to receive in-service on the completion of Psychosocial Evaluation by the Clinical Supervisor and by the Department of Behavioral Health Technical Analyst TBA. In addition, a full-time Counselor with clinical experience will be hired. Clinical Supervisor will monitor to insure compliance through chart reviews and weekly supervision. |