INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Methadone Monitoring conducted on October 30, 2019 through October 31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to document the completion of 12 clock hours of annual training required for the Project Director for the facility's January 1, 2017 through December 31, 2017 training year.
Employee # 1's employee file documented 3 hours of annual training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will complete at least 12 clock hours of training annually in areas such as:
Fiscal policy. (ii) Administration. (iii) Program planning. (iv) Quality assurance. (v) Grantsmanship. (vi) Program licensure. (vii) Personnel management. (viii) Confidentiality. (ix) Ethics. (x) Substance abuse trends. (xi) Developmental psychology. (xii) Interaction of addiction and mental illness. (xiii) Cultural awareness. (xiv) Sexual harassment. (xv) Relapse prevention. (xvi) Disease of addiction. (xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
In order to assure continued compliance, the Program Director will achieve the total number of training hours required each year no later than 11/30/19 of each year.
The Executive Assistant will be responsible to monitor the Project Director's educational hours on a quarterly basis to assure the Program Director meets the 12 hours of education by the deadline of 11/30/19.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's January 1, 2017 through December 31, 2017 training year in one employee file.
Employee # 3's employee file documented 4 hours of annual training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each counselor shall complete at least 25 clock hours of training annually.
In order to assure continued compliance, all counselors are now mandated to achieve the total of 25 clock hours of training annually no later than 11/30/19. A memo was sent to all Counselors regarding this directive on 11/7/19.
In order to assure continued compliance, the Chief Nursing Officer will be responsible to monitor the counselors' annual educational trainings on a quarterly basis to assure they will meet the compliance deadline of 11/30/19
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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
The facility failed to ensure that, in the patient bedrooms, there was a storage area for clothing for each patient occupying every bedroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Non-Hospital patient bedrooms will now have a storage area for clothing for each patient occupying the bedroom.
Administration ordered six (6) storage bins for the six (6) Non-Hospital patient beds on 11/11/19. Once the storage bins arrive, Hospital Maintenance will place the storage bins in the appropriate rooms.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to identify, on their fire drill log, which exit route was used during drills conducted from January 2018 to September 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill form was revised on 11/7/19 to include "Exit Route used during Drill". Also, a memo was sent to the staff person conducting fire drills on 11/7/19 to clearly document the exit route used during the drill.
In order to assure continued compliance, the Performance Improvement Coordinator will review the monthly fire drills to assure the exit route used during drills is clearly documented on the Fire Drill form. The results of this review will be presented to the Performance Improvement Committee on a quarterly basis for six (6) months.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual's identity, which is to include the name, address and date of birth, prior to the administration of a narcotic agent in three of eight applicable client records.
Client # 1 was admitted to the inpatient non-hospital detoxification level of care on September 19, 2019 and was discharged on September 24, 2019.
Client # 9 was admitted to the inpatient hospital detoxification level of care on August 23, 2019 and was discharged on September 20, 2019.
Client # 11 was admitted to the inpatient hospital detoxification level of care on September 16, 2019 and was discharged on September 21, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Hospital's Intake Worker currently verifies an individual's identity with the insurer on the Identification Verification Form which has the Patient's Name, Date of Birth, Gender, & Race. The Intake worker calls the insurer with this information and obtains verification. The Intake Work then documents with whom he spoke with and dates the form.
Also, a web cam will be purchased and installed on the Intake Worker's computer by 12/31/19 in order to take a photo of those clients who present for admission without photo ID.
The Hospital's Educator will also in-service the Nursing Staff to review the individual's identify, which is to include, the following: photo ID, name, address and date of birth prior to the administration of a narcotic agent.
In order to assure continued compliance, the Performance Improvement Coordinator will review random medical records to assure the Identification Verification Form is completed when individuals' present with no Identification. This review will be done for at least 6 months or until consistent compliance is achieved.
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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
The facility failed to document the physician's face to face contact and one-year documentation prior to the client's initial dose in one of one applicable record.
Client # 9 was admitted to the inpatient hospital detoxification level of care on August 23, 2019 and was discharged on September 20, 2019. The client was on an ETOH detox and a methadone induction. The client's initial dose was on August 23, 2019. The physician performed the face to face physical health assessment of the client on August 23, 2019; however, the physician did not document the basis for the determination of current dependency and evidence of a 1-year history of addiction.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
A memo was sent to the Medical Staff on 11/11/19 reminding them to document a fact to fact contact, as well as, one year addiction documentation prior to the client's initial dose of a narcotic agent.
In order to assure continued compliance, the Performance Improvement Coordinator will review random monthly charts to assure the Medical Staff is documenting a face to face contact, as well as, the one (1) year of addiction history. The results from this study will be presented to the Performance Improvement Committee for six (6) months or until consistent compliance is achieved. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to include documentation that they informed female clients of the potential risks to her or her unborn child of continued use of illicit drugs, or withdrawal from a narcotic drug prescribed by the program in one of four applicable client records.
Client # 9 was admitted to the inpatient hospital detoxification level of care on August 23, 2019 and was discharged on September 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Consent to Treat with An Approved Narcotic Drug form is completed on all females upon admission by the Admissions Intake Worker. However, the Nursing Staff will be in-serviced on the proper completion of this form by the Hospital's Educator by 11/22/19 as the Nursing staff performs admissions to the Program after normal business hours and on the weekends.
In order to assure continued compliance, the Performance Improvement Coordinator will review all female admissions to the Program on a monthly basis and report the findings to the Performance Improvement Committee for six (6) months or until consistent compliance is achieved.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to ensure that each client signed an informed consent to treat prior to the administration of a narcotic agent in one of eight client records.
Client # 9 was admitted to the inpatient hospital detoxification level of care on August 23, 2019 and was discharged on September 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There was a signed Informed Consent to Treatment in the paper copy of this patient's medical record, however, the inspector was not given the paper portion of the medical record at time of the inspection.
The Counselors were re-educated by the Program Director by 11/15/19 to obtain an Informed Consent to Treat form prior to the administration of a narcotic agent.
Also, the Counselors will be re-educated by the Hospital Educator on the proper completion of the Voluntary Consent to Release Information prior to the disclosure of information.
In order to assure continued compliance, the Performance Improvement Coordinator will review random monthly charts to assure the:
1) The Consent to Treatment form is signed by the prior to a Narcotic Agent being administered;
2) The Informed & Voluntary Consent to Release Information form is signed by the client prior to the disclosure of information.
The results from these reviews will be reported to the Performance Improvement Committee for six (6) months or until consistent compliance has been achieved.
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711.61(c)(6) LICENSURE Psychosocial Evaluation
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation that included the evaluation of the client and/or recommendations based on information gathered from client histories. The psychosocial evaluation only documented what the client stated in two of six applicable records reviewed.
Client # 2 was admitted on December 28, 2017 and was discharged on January 2, 2018. The psychosocial evaluation was documented on December 29, 2017.
Client # 5 was admitted on October 28, 2019 and was active at the time of the inspection. The psychosocial evaluation was documented on October 29, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Counseling Staff will be re-educated by the Program Director by 11/15/19 on the proper completion of a psychosocial evaluation to include the evaluation of the client and/or recommendations based on information gathered from client histories.
In order to assure continued compliance, the Performance Improvement Coordinator will conduct random chart reviews to assure the Psychosocial Evaluation includes the evaluation of the client and/or recommendations based on the information gathered from the client's histories. The results of this review will be presented to the Performance Improvement Committee for six(6) months or until full compliance is consistently achieved.
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711.62(c)(2)(i) LICENSURE Name of Person/agency/organization
711.62. 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
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent form in one of seven client records.
Client # 2 was admitted on December 28, 2017 and was discharged on January 2, 2018. There was a consent to release information form signed and dated by the client on December 28, 2017; however, the consent form did not include a specific name of the person, agency or organization.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Counselors will be re-educated by the Program Director on the proper completion of a Disclosure of Information form by 11/15/19. The Disclosure form must include the following information: name of the person, agency/organization to whom the disclosure is being made to on a Consent form.
In order to assure continued compliance, the Performance Improvement Coordinator will conduct random monthly chart reviews to assure the Disclosure of Information form is being completed properly and thoroughly. The results of this review will be forwarded to the Performance Improvement Committee for six (6) months or until consistent compliance is achieved.
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710.21(b)(4) LICENSURE Admission - Detoxification
§ 710.21. Admission-detoxification.
(b) Admission procedures shall include documentation of the following:
(4) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation that included the evaluation of the client and/or recommendations based on information gathered from client histories. The psychosocial evaluation only documented what the client stated in two of five records reviewed.
Client #8 was admitted on October 28, 2019 and was still active at the time of the inspection. The psychosocial evaluation was documented on October 29, 2019.
Client #11 was admitted on September 16, 2019 and was discharged on September 21, 2019. The psychosocial evaluation was documented on September 17, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Counseling Staff will be re-educated by the Program Director by 11/15/19 on the proper completion of a psychosocial evaluation to include the evaluation of the client and/or recommendations based on information gathered from client histories.
In order to assure continued compliance, the Performance Improvement Coordinator will conduct random chart reviews to assure the Psychosocial Evaluation includes the evaluation of the client and/or recommendations based on the information gathered from the client's histories. The results of this review will be presented to the Performance Improvement Committee for six(6) months or until full compliance is consistently achieved.
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710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of five client records reviewed. Additionally, three of five client records had consent to release information forms that were missing elements.
Client # 9 was admitted on August 23, 2019 and was discharged on September 20, 2019. There was documentation of staff communicating and coordinating aftercare with another provider on September 9, 2019; however, there was no consent to release information form on file prior to disclosure.
Client # 10 was admitted on July 27, 2018 and was discharged on August 1, 2018. There was a consent to release information form signed and dated by the client on July 27, 2018; however, the consent form was missing the specific name of the person, agency or organization to whom disclosure would be made.
Client # 11 was admitted on September 16, 2019 and was discharged on September 21, 2019. There was a consent to release information form signed and dated by the client on September 16, 2019; however, the consent form was missing the specific name of the person, agency or organization to whom disclosure would be made and it was missing the specific items to be disclosed.
Client # 12 was admitted on October 8, 2019 and was discharged on October 13, 2019. There were two consent to release information forms signed and dated by the client on October 8, 2019; however, both consent forms were missing the specific name of the person, agency or organization to whom disclosure would be made and one was missing the specific items to be disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Counselors will be re-educated by the Program Director by 11/15/19 to obtain an Informed and Voluntary Consent to Release Information prior to the disclosure of information.
In order to assure continued compliance, the Performance Improvement Coordinator will review random monthly charts to assure the Informed & Voluntary Consent to Release Information form is signed by the client prior to the disclosure of information. The results from this review will be reported to the Performance Improvement Committee for six (6) months or until consistent compliance has been achieved.
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