INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Kensington Hospital Outpatient Treatment Program 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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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on the review of patient records, the program failed to document the nature of prenatal support provided by the narcotic treatment program in one of two applicable patient records reviewed.
Patient #9 was admitted on February 27, 2017 and was an active patient at the time of the inspection. There was no documentation in the patient record that the patient was ever offered prenatal support upon the discovery of the client becoming pregnant.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Counselor was re-educated by the Director of Behavioral Health Services on 6/8/2021 to document each patient that reports a pregnancy to coordinator/outreach prenatal supports.
Treatment team were immediately educated on 5/26/2021 staff meeting of requirements with patients pregnant and the importance of prenatal supports by the narcotic treatment program.
In order to assure continued compliance, the Director of Behavioral Health Services will review all female charts after admission to program on a monthly basis and report the finding to the Performance Improvement Committee for six (6) months until consistent compliance is achieved.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the program failed to document a random urinalysis at least monthly in four of ten patient records reviewed.
Patient #1 was admitted on July 7, 2020 and was an active patient at the time of the inspection. A random urinalysis was not documented in the record for the months of March 2021 and April 2021.
Patient #4 was admitted on July 1, 2019 and was discharged on October 2, 2020. A random urinalysis was not documented in the record for the months of June 2020 and July 2020.
Patient #5 was admitted on March 30, 2017 and was discharged on August 19, 2020. A random urinalysis was not documented in the record for the months of April 2020, May 2020 and June 2020.
Patient #10 was admitted on May 6, 2015 and was an active patient at the time of the inspection. A random urinalysis was not documented in the record for the months of January 2021, March 2021 and April 2021.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services re-educated the Counselors on 6/8/2021 to monitor their e-mails through the EMR daily to be alerted to the fact that a client is scheduled to a have a monthly urine drug screen completed.
In order to assure continued compliance, the Register/Clerk will conduct monthly monitoring of randomly selected records for each counselor to assure monthly urine drug screens are being done. The results of the findings will be reported to the Performance Improvement Committee on a quarterly basis for six (6) months until consistent compliance is achieved.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first two years in two applicable patient records reviewed.
Patient #1 was admitted on July 7, 2020 and was an active patient at the time of the inspection. There was no documentation in the patient record that the patient received 2.0 of the 2.5 psychotherapy hours required for the months of December 2020 and January 2021, and 1.0 of the 2.5 psychotherapy hours required for the months of November 2020, February 2021, March 2021 and April 2021.
Patient #4 was admitted on July 1, 2019 and was discharged on October 2, 2020. There was no documentation in the patient record that the patient received any of the 2.5 psychotherapy hours required for the month of June, 2.0 of the 2.5 psychotherapy hours required for the months of April 2020, May 2020 and August 2020, and 1.0 of the 2.5 psychotherapy hour required for the month of July 2020.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services provided supervision and training to the counselors/ therapists on the topic of individualized psychotherapy services and required treatment on 6/2/2021.
In order to assure continued compliance, the Register/Clerk will conduct monthly monitoring of randomly selected records for each counselor to assure patients that are receiving the required 2.5 hours of psychotherapeutic services per month. The results of the findings will be reported to the Performance Improvement Committee on a quarterly basis for six (6) months until consistent compliance is achieved.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the program failed to provide each patient at least one hour per month of group or individual psychotherapy during the third and fourth year of treatment in two applicable patient records reviewed.
Patient #5 was admitted on March 30, 2017 and was discharged on August 19, 2020. There was no documentation in the patient record that the patient received any psychotherapy hours for the months of February 2020 and July 2020.
Patient #9 was admitted on February 27, 2017 and was an active patient at the time of the inspection. There was no documentation in the patient record that the patient received any psychotherapy hours for the months of December 2020 and January 2021.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services provided supervision and training to the counselors/ therapists on the topic of individualized psychotherapy services and required treatment on 6/2/2021. Supervision will occur on an ongoing basis.
In order to assure continued compliance, the Register/Clerk will conduct monthly monitoring of randomly selected records for each counselor to assure patients that are receiving the required minimum of 1 hour per month of psychotherapeutic services. The results of the findings will be reported to the Performance Improvement Committee on a quarterly basis for six (6) months until consistent compliance is achieved.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the program failed to provide a patient with at least one hour of group or individual psychotherapy every two months, after the fourth year of treatment in one applicable patient record reviewed.
Patient #10 was admitted on May 6, 2015 and was an active patient at the time of the inspection. There was no documentation in the patient record that the patient received any psychotherapy hours for the months of November 2020 and December 2020 and only received .5 psychotherapy hours for the months of March 2021 and April 2021.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services provided supervision and training to the counselors/therapists on the topic of individualized psychotherapy services and required treatment on 6/2/2021.
In order to assure continued compliance, the Register/Clerk will conduct monthly monitoring of randomly selected records for each counselor to assure patients that are receiving the required minimum of 1 hour per month of psychotherapeutic services. The results of the findings will be reported to the Performance Improvement Committee on a quarterly basis for six (6) months until consistent compliance is achieved.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the program failed to document the results of an annual physical examination given by the narcotic treatment program which included an annual reevaluation by the narcotic treatment physician in one of ten patient records reviewed.
Patient #5 was admitted on March 30, 2017 and was discharged on August 19, 2020. An annual physical exam was documented in the patient record on March 13, 2019 and the next annual physical exam was due no later than March 13, 2020 and then March 13, 2021; however, there were no annual physical exams documented in the patient record at the time of the inspection for the years of 2020 and 2021.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
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Plan of Correction
The Narcotic Treatment Physician has been made aware of his responsibility to document all annual and re-evaluations physical examinations during staff meeting on 5/26/2021.
The Register/Clerk will compile a monthly list of patients who have admission anniversaries each month and schedule each patient according to list. The list of patients will be sent to both the Counselors/ Therapists, Narcotic Treatment Physician, and the Director of Behavioral Health Services.
In order to assure continued compliance, the Director of Behavioral Health Services will conduct monthly monitoring of selected records for each month on behalf for each counselor to assure that there is documentation of both annual and re-evaluation physical examinations by the Narcotic Treatment Physician. The results of the findings will be reported to the Performance Improvement Committee on a quarterly basis for six (6) months until consistent compliance is achieved.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of patient census data and the Methadone Monitoring Questionnaire, the program failed to file a written Unusual Incident Report with the Department within 48 hours following a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On May 29, 2020, it was documented in discharge paperwork that an active client was discharged due to being deceased. However, there was no documentation that the death was reported to the Department.
On June 24, 2020, it was documented in discharge paperwork that an active client was discharged due to being deceased. However, there was no documentation that the death was reported to the Department.
On December 16, 2020, it was documented in discharge paperwork that an active client was discharged due to being deceased. However, there was no documentation that the death was reported to the Department.
On April 13, 2021, it was documented in discharge paperwork that an active client was discharged due to being deceased. However, there was no documentation that the death was reported to the Department.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Counselors/Therapists effective 5/26/2021 will be responsible of reporting all Unusual Incidents to the Department of Drug and Alcohol Programs (DDAP) within 48 hours of the Unusual Incident. A copy of the Unusual Incident Report and the confirmation of submission to DDAP will be maintained within the patient's chart and with the Director of Behavioral Health Services.
The Director of Behavioral Health Services provided in-service training on the completion of Unusual Incidents Report for proper and timely reporting of Unusual Incident Reports to the department within 48 hours following the unusual event on 6/3/2021.
In order to assure continued compliance, the Register/Clerk will conduct monthly monitoring of randomly selected records for each counselor to assure any Unusual Incidents are being done within 48 hours of incident occurrence. The results of the findings will be reported to the Program Director on a quarterly basis for six (6) months until consistent compliance is achieved.
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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 the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in eight of ten client records reviewed.
Client #2 was admitted on December 22, 2016 and was discharged on December 16, 2020. An updated treatment and rehabilitation plan was documented in the record on February 20, 2020 and the next update was due no later than April 20, 2020; however, the updated plan was not documented in the record until August 20, 2020.
Client #4 was admitted on July 1, 2019 and was discharged on October 2, 2020. An updated treatment and rehabilitation plan was documented in the record on March 13, 2020 and the next update was due no later than May 13, 2020; however, the updated plan was not documented in the record until July 29, 2020.
Client #5 was admitted on March 30, 2017 and was discharged on August 19, 2020. An updated treatment and rehabilitation plan was documented in the record on March 19, 2020 and the next update was due no later than May 19, 2020; however, the updated plan was not documented in the record until August 3, 2020.
Client #6 was admitted on March 4, 2005 and was an active client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on March 25, 2020 and the next update was due no later than May 25, 2020; however, there was no updated plan documented in the record at the time of the inspection.
Client #7 was admitted on April 21, 2014 and was an active client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on January 5, 2021 and the next update was due no later than March 5, 2021; however, there was no updated plan documented in the record at the time of the inspection.
Client #8 was admitted on August 8, 2011 and was an active client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on February 19, 2020 and the next update was due no later than April 19, 2020; however, the updated plan was not documented in the record until July 15, 2020.
Client #9 was admitted on February 27, 2017 and was an active client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on February 21, 2020 and the next update was due no later than April 21, 2020; however, the updated plan was not documented in the record until July 22, 2020.
Client #10 was admitted on May 6, 2015 and was an active client at the time of the inspection. An updated treatment and rehabilitation plan was documented in the record on February 18, 2020 and the next update was due no later than April 18, 2020; however, the updated plan was not documented in the record until July 24, 2020.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services provided supervision and training to the Counselors/ Therapists on the topic treatment planning on 6/3/2021.
In order to assure continued compliance, the Register/Clerk will conduct monthly monitoring of randomly selected records for each counselor to assure patients treatment plans are being updated and completed. The results of the findings will be reported to the Performance Improvement Committee on a quarterly basis for six (6) months until consistent compliance is achieved.
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711.93(a)(7) LICENSURE Follow-up Information
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:
(7) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document a complete client record on an individual, which is to have included follow-up information, in three of four applicable records reviewed.
Client #2 was admitted on December 22, 2016 and was discharged on December 16, 2020. There was no follow-up information documented in the client record.
Client #3 was admitted on Mary 6, 2020 and was discharged on May 25, 2020. There was no follow-up information documented in the client record.
Client #5 was admitted on March 30, 2017 and was discharged on August 19, 2020. There was no follow-up information documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services provided supervision and training to the Counselors/ Therapists on the topic appropriate follow-up procedures on 6/3/2021.
In order to assure continued compliance, The Director of Behavioral Health Services will conduct monthly monitoring of randomly selected records of patients being discharged and review chart for proper follow-up documentation. The results of the findings will be reported to the Performance Improvement Committee on a quarterly basis for six (6) months until consistent compliance is achieved.
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711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the project failed to document the name of the person, agency, or organization on an informed and voluntary consent to release information form in two of ten client records reviewed.
Client #1 was admitted on July 7, 2020 and was an active client at the time of the inspection. Two release of information forms, signed and dated by the client on July 9, 2020 and August 19, 2020, failed to include the name of the person, agency or organization to whom a disclosure is made.
Client #9 was admitted on February 27, 2017 and was an active client at the time of the inspection. A release of information form, signed and dated by the client on July 31, 2020, failed to include the name of the person, agency or organization to whom a disclosure is made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Counselor was re-educated by the Director of Behavioral Health Services on 6/8/2021 during individual supervision to document each patients chart according to regulation standards on Confidentiality by providing appropriate information of the name of the person, agency and/or organization to whom disclosure is being made. Both Patient#1 and Patient #9 charts were reviewed during supervision with the Counselor for visual understanding. Client #9 had a new Informed & Voluntary Consent to Release form completed and signed by the counselor and the client on 6/14/2021. Client #1 is currently incarcerated, however, if and when Client #1 returns to the Program, a new Informed & Voluntary Consent to Release form will be completed and signed by both the counselor and the client.
The Director of Behavioral Health Services provided supervision and training to the Counselors/ Therapists on the topic of Client Records/Confidentiality and proper documentation on 5/26/2021 during staff meeting.
In order to assure continued compliance, the Director of Behavioral Health Services and the Lead Therapist and Director of Behavioral Health Services will conduct random chart checks weekly to ensure compliance with the regulation on a monthly basis and report the finding to the Performance Improvement Committee for six (6) months until consistent compliance is achieved.
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711.93(c)(2)(ii) LICENSURE Specific Info. Disclosed
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
Based on the review of client records, the project failed to document the specific information to be disclosed on an informed and voluntary consent to release information form in two of ten client records reviewed.
Client #1 was admitted on July 7, 2020 and was an active client at the time of the inspection. Two blank release of information forms, signed and dated by the client on July 9, 2020 and August 19, 2020, did not include the specific information to be disclosed.
Client #9 was admitted on February 27, 2017 and was an active client at the time of the inspection. A release of information form for a court system, signed and dated by the client on January 20, 2021, did not include the specific information to be disclosed. Additionally, a blank release of information form, signed and dated by the client on July 31, 2020, did not include the specific information to be disclosed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Counselor was re-educated by the Director of Behavioral Health Services on 6/8/2021 during individual supervision to document each patients chart according to regulation standards on Confidentiality by providing appropriate specific information being disclosed and released. Client #1 and Client #9 charts were reviewed during supervision with the Counselor for visual understanding. Client #9 had a new Informed & Voluntary Consent to Release form completed which now includes the specific information to be disclosed. The new Consent to Release form was completed and signed by the counselor and client on 6/14/2021. Client #1 is current incarcerated, therefore, if and when the client should return to the Program. a new Consent to Release form will be completed to include specific information to be disclosed.
The Director of Behavioral Health Services provided supervision and training to the Counselors/ Therapists on the topic of Client Records/Confidentiality and proper documentation on 5/26/2021 during staff meeting.
In order to assure continued compliance, the Director of Behavioral Health Services and the Lead Therapist and Director of Behavioral Health Services will conduct random chart checks weekly to ensure compliance with the regulation on a monthly basis and report the finding to the Performance Improvement Committee for six (6) months until consistent compliance is achieved.
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