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, for the detoxification of patients from opioid addiction. This inspection was conducted on October 29 and 30, 2007 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 corrections are due on November 20, 2007.
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Plan of Correction
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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 random patient record review, the narcotic treatment physician failed to document the basis for determining current dependency, but rather used a pre-printed check off system without the supporting documentation. Specifically, patient # 1 current dependency was indicated by the physician on the check off system as having a positive opiate urine drug screen on October 27, 2007, but in reality, patient 1 urine specimen was obtained and tested on October 28, 2007. In addition, patients # 2 and 5 also had all areas checked off by the physician without the supporting documentation.
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Plan of Correction
This issue was referred to the Executive Committee of the Medical Staff at their meeting of 11/21/07. Physicians were reminded to document the basis for determining current dependency. The Clinical Supervisor will monitor for compliance by monthly random chart reviews. |
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 a review of five random patient records and the written consent to release information forms, it was determined that the facility failed to complete the consent with the specific information required to ensure a fully informed consent was obtained from each patient. Specifically, in records #1, 2, and 3 the only information specified to be released to CBH, the funding entity, was the patient's PCPC scores, thus limiting what the program could actually release. Patient record # 5 was being referred to another narcotic treatment program and the only information specified on the consent signed by the patient was "presence in treatment", again limiting what could be released to much less than that which is needed to complete the referral process.
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Plan of Correction
The staff was in-serviced on 11/21/07 to complete the consent with all specific information required to ensure a fully informed consent is obtained. The Clinical Supervisor will monitor compliance by random monthly chart reviews. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
The facility failed to provide policy and procedures that ensure accurate tracking of the urine specimen from collection to shipment to the laboratory to minimize misidentification and tracing the specimen back to the donor.
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Plan of Correction
The Hospital's Policy & Procedure will be revised to reflect measures taken to prevent misidentification. The revised policy will be presented to the Executive Committee of the Medical Staff at their January 16,2008 meeting for review and approval. The policy will then be forwarded to the Board of Directors at their January 22,2008 for review and approval. Once approved, the staff will be in-serviced on the policy. The Clinical Supervisor will be responsible for the revision to the policy. |
715.17(c)(5) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(5) Security of all substances. A narcotic treatment program shall develop and implement written policies and procedures to minimize the likelihood of loss, theft or misuse of an agent or another controlled substance as well as a plan of action if a loss, theft or misuse does occur. In the event of loss, theft or misuse, the Federal and State statutes and regulations regarding reporting shall be followed.
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Observations
Based on the review of the program policy and procedure manual, the facility failed to address the reporting (per incident reporting requirements), any event of loss, theft or misuse of an agent to the Department of Health, Division of Drug and Alcohol Program Licensure.
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Plan of Correction
The Hospital does have a Medication Diversion Control Policy, however, the policy was not maintained in the Policy & Procedure manual. However, a copy of the Diversion Control policy has been placed in the Non-Hospital Policy & Procedure manual in order to prevent future non-compliance.
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715.18(b) LICENSURE Rehabilitative services
(b) A patient shall also have the opportunity to access legal services.
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Observations
The facility failed to demonstrate that the patients have the opportunity to access legal services as confirmed by interviews of staff, review of linkage agreements and the policy manual.
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Plan of Correction
A current Referral Agreement was obtained for legal services. In addition, all Referral Agreements will be updated in a timely manner to prevent non-compliance. The Administrative Assistant will be response to contact providers for updated Agreements. The Clinical Supervisor will monitor to ensure compliance. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the random review of five patient records, the facility failed to demonstrate that, with written consent of the patient, the required information was transferred for patients #2, 4, and 5.
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Plan of Correction
The staff was in-serviced by the Clinical Supervisor on 11/21/07 to demonstrate that, with written consent of the patient, the required information was transferred for patients. The Clinical Supervisor will monitor for compliance by random monthly chart reviews. |
715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Based on random review of five patient records, the facility failed to provide a complete medical history by not addressing family medical history.
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Plan of Correction
This issue was referred to the Executive Committee of the Medical Staff at their meeting of 11/21/07. Physicians were reminded to address the patient's family medical history as part of the medical history of the patient. The Clinical Supervisor will monitor compliance by monthly random chart reviews. |
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 random review of five patient records, the facility failed to obtain a Mantoux test for tuberculosis from four of the five patients reviewed, #1, 2, 3 and 5.
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Plan of Correction
This issue was referred to the Executive Committee of the Medical Staff at their meeting of 11/21/07. Physicians were reminded to use the checklist to order a PPD test upon admission. Patient cannot refuse the test. If the patient states they have been tested but confirmation cannot be verified, the test must be re-ordered. The Performance Improvement Coordinator will conduct montly random chart reviews to assure compliance. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on random review of five patient records, the clinical staff failed to provide the patient progress and status in the progress notes after each significant contact. Rather, the counselors had written a generalized intake note and then a discharge note minimally discussing where the patient was to go after discharge.
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Plan of Correction
The staff have been in-serviced on 11/21/07 to document a progress note after each significant contact. The Clinical Supervisor will also monitor for compliance by monthly random 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 random review of five patient records, the facility failed to ensure an evaluative assessment of the historical data obtained, but rather repeated the historical data and added patient statements without counselor insight. In addition, patient #1 did not have a psychosocial evaluation completed.
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Plan of Correction
The counseling staff was in-serviced on 11/21/07 to complete a psychosocial evaluative assessment on historical data obtained from the patient. The Clinical Supervisor will monitor for compliance by monthly random chart reviews. |
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 random review of five patient records, the narcotic treatment physician failed to document the basis for determining current dependency, but rather used a pre-printed check off system without the supporting documentation. In particular, patient # 1 current dependency was identified by the physician on the check off system as having a positive opiate urine drug screen on October 27, 2007, but in reality, patient 1 urine specimen was obtained and tested on October 28, 2007. In addition, patients # 2 and 5 also had all areas checked off by the physician without the supporting documentation.
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Plan of Correction
This issue was referred to the Executive Committee of the Medical Staff at their meeting of 11/21/07. Physicians were reminded that in addition to utilizing the checklist, they must document the basis for determining current dependency. The Clinical Supervisor will monitor for compliance by monthly random chart reviews. |
715.24(4)(iii) 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:
(4) Minimum requirements for short-term narcotic detoxification treatment are as follows:
(iii) The narcotic treatment program shall develop a treatment plan. The patient's counselor shall monitor the patient's progress toward the goal of short-term narcotic detoxification and possible drug-free treatment referral.
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Observations
Based on random review of five patient records, the facility failed to develop an individual treatment plan for each patient, but rather had one pre-printed standardized treatment plan without individualizing the content based on the particular patient. Having a blank space to fill in drug of choice is not sufficient individualization.
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Plan of Correction
The Treatment Plan will be reviewed and revised by 12/7/07. The revised form will be presented to the Addictions Committee and Medical Records Committee for review and approval. The Executive Committee of the Medical Staff will then receive the form for review and approval at their meeting of 1/16/98 and then finally the Board of Directors will review and approve at their meeting of 1/22/08. Staff will be in-serviced on the use of the new form as well. The Clinical Supervisor will monitor for compliance by monthly random chart reviews. |
715.28(b)(1-4) LICENSURE Unusual incidents
(b) These policies and procedures shall include the following:
(1) Documentation of the unusual incident.
(2) Prompt review and investigation.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on review of the policy and procedure manual and staff interview, the facility failed to include implementation and ongoing monitoring of the corrective action plan that addressed the unusual incident.
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Plan of Correction
The existing policy will be revised by the Clinical Supervisor by 12/7/07 to include the following information:
1) written documentation of the unusual incident; 2) prompt review & investigation of the unusual incident; 3) implementation of a timely & appropriate corrective action plan, when needed; 4) on-going monitoring of the corrective action plan. The revised policy will be presented to the Executive Committee of the Medical Staff at their meeting of 1/16/08 for review and approval. The Board of Directors will receive the revised policy at their meeting of 1/22/08 for review and approval. Staff will receive in-serving on the revised policy by 1/30/08. |