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 January 25 and 28, 2011 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 18, 2011.
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Plan of Correction
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715.20 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.
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Observations
Based on a review of administrative documentation and patient records, the facility failed to develop an appropriate transfer policy to another narcotic treatment for patients completing detoxification services at the facility.
The findings include:
The policy and procedure manual was reviewed on January 28, 2011 to determine the process for the referral of a patient being transferred to another narcotic treatment program.
On page 40 of the policy and procedure manual, under the title of "715.20 Patient Transfers", there was documentation that specified "a referral to another narcotic program after a completed detox is not to be considered a transfer". Said policy failed to provide consideration to the fact that following a patient's completion of the facility's opiate detoxification program, a patient is no longer eligible for further narcotic treatment as there is no longer a current physiological dependency, a requirement for admission to a narcotic treatment program. Additionally, a review of patient records revealed documentation that specified patient transfers to a narcotic treatment program upon completion of the patient's detoxification, a factor that indicated a practice that was inconsistent with the facility's policy and procedure.
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Plan of Correction
The written Transfer Policies and Procedures will be revised to conform to the regulations and insure consistency. Once the policies are revised, staff will be in-serviced on the policies. The Program Director will be responsible to revise the policies, in-service the staff and implement the revised policies. This will be completed by 4/6/11. |
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 a review of patient records and discussion with administrative staff, the narcotic treatment program failed to transfer the required patient files to the receiving narcotic treatment program in three of three patient records.
The findings include:
Eight patient records were reviewed January 25 and 28, 2011. Three patient records showed clear documentation the patient was referred to another narcotic treatment program. The transfer to a narcotic treatment program following the completion of an opiate detoxification is both inconsistent with facility policy as well as the regulatory requirement that specifies that a patient must be physiologically dependent to opiates for admission to a narcotic treatment program. The facility's policy pertaining to transfer specified that "a referral to another narcotic program after a completed detox is not to be considered a transfer".
Patient # 5 was admitted January 22, 2011 and completed opiate detoxification January 27, 2011. A consent restricted to 4 PA Code 255.5 was signed by the patient. There was no other documentation of what materials were sent to the receiving facility.
Patient # 6 was admitted January 21, 2011 and a discharge summary had not been completed at the time of the review of this record. However, an aftercare plan was developed and a referral made to another narcotic treatment program was made January 25, 2011. A consent restricted to 4 PA Code 255.5 was signed by the patient. There was no other documentation of what materials were sent to the receiving facility.
Patient # 7 was admitted November 16, 2010 and completed opiate detoxification November 22, 2010. An aftercare plan was documented and signed by the patient on November 18, 2010 for the patient to go to a narcotic treatment program for maintenance on November 24, 2010. A consent restricted to 4 PA Code 255.5 was signed by the patient. There was no other documentation of what materials were sent to the receiving facility.
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Plan of Correction
The Transfer document is in the process of being revised to include the following: admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests and current status of the patient, as well as, the written consent of the patient. The Program Director will be responsible to revise the transfer document and in-service the staff on the new document and procedure. This will be completed by 4/6/11. The Performance Improvement Coordinator will monitor charts for a period of three (3) months to assure compliance. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records and discussion with administrative staff, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in three of three patient records.
The findings include:
Eight patient records were reviewed January 25 and 28, 2011. Three patient records revealed documentation that patients were referred to another narcotic treatment program.
Patient # 5 was admitted January 22, 2011 and completed opiate detoxification January 27, 2011. There was no other documentation that specified what materials were sent to the receiving facility.
Patient # 6 was admitted January 21, 2011 and a discharge summary had not been completed at the time of the review of this record. However, an aftercare plan was developed and a referral made to another narcotic treatment program was made January 25, 2011. There was no other documentation of what materials were sent to the receiving facility.
Patient # 7 was admitted November 16, 2010 and completed opiate detoxification November 22, 2010. An aftercare plan was documented and signed by the patient on November 18, 2010 for the patient to go to a narcotic treatment program for maintenance on November 24, 2010. There was no other documentation of what materials were sent to the receiving facility.
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Plan of Correction
The Transfer document will be revised to include and list which specific materials were sent to the receiving narcotic treatment program. The Program Director will provide clinical staff with an in-service by 4/6/11. One the document is completed, the Performance Improvement Coordinator will monitor charts for a period of three (3) months to assure compliance. |
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 discussion with administrative staff, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in four of five patient records.
The findings include:
Eight patient records were reviewed January 25 and 28, 2011. Five patient records were reviewed for completed psychosocial evaluations.
Patient record # 1 was admitted August 11, 2010 and discharged August 15, 2010. An evaluation had not been completed.
Patient records # 6, 7 and 8 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment of the information collected.
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Plan of Correction
Counselors will receive comprehensive series of trainings on the completion of the Psychosocial through the Department of Behavioral Health (DBH) Technical Assistance by 4/6/11. The Program Director will monitor charts for a period of three (3) months to assure compliance. |
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 and administrative documentation, the facility failed to document follow-up information according to regulation and the facility's policy and procedures in four of five patient records.
The findings include:
The policy and procedure manual was reviewed on January 28, 2011 for the follow up process for all discharged patients. The policy states that all patients will receive a follow-up attempt seven days post discharge.
Five patient records were reviewed for follow up documentation.
Patient # 1 was discharged therapeutically August 15, 2010. Documentation of follow- up attempts were not found in either the patient record or the follow up binder provided for review.
Patient # 2 was discharged December 5, 2010 with a scheduled referral appointment December 7, 2010. The follow-up contact was not completed until December 17, 2010, ten days post discharge.
Patient # 3 was discharged November 29, 2010 with a scheduled referral appointment November 29, 2010. The follow-up contact was not completed until December 29, 2010, thirty days post discharge.
Patient # 7 was discharged November 22, 2010 with a scheduled referral appointment November 24, 2010. the follow-up contact was not completed until December 7, 2010, thirteen days post referral date.
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Plan of Correction
Staff in-serviced on Kensington Hospital Policy regarding follow-up and reminded the importance of follow-up in a timely manner.
Clinical Supervisor will review compliance on a monthly basis for 6 months (02/11 till 08/11) and will generate a report. |