INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2010 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. The following deficiencies were identified during this inspection and a plan of correction is due on October 11, 2010.
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Plan of Correction
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on survey results, interviews and a tour of the facility the residential facility failed to install slip resistant surfaces in showers.
Findings:
A tour of the non-hospital detoxification unit was conducted on September 10, 2010. Two of two fiberglass showers located in the non-hospital detoxification unit failed to have slip resistant surfaces.
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Plan of Correction
Slip Resistant strips have been installed in both showers. Completed 9/12/10. |
711.14(b)(5) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on survey results, interviews and a physical plant tour the non-hospital detoxification unit failed to notify the Department of a change in authorized capacity.
Findings:
A physical plant tour was completed on September 10, 2010. The authorized five-bed dormitory, located on the second floor of the hospital, had seven beds.
The facility director indicated cots/beds are set up in the unit dormitory in order to accommodate admissions.
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Plan of Correction
The five bed dormitory now contains the authorized number of beds (5). Completed 9/10/10. |
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
Based on survey results, interviews and patient records the non-hospital detoxification unit failed to obtain voluntary and informed consents.
Findings:
On September 10, 2010 seven patient records were reviewed for compliance relative to informed and voluntary consents to release information. Three of seven records reviewed failed to include documentation of the name of the person, agency or organization to whom the disclosure was made. Client records # 1, 4 and 5 included signed authorizations to release information, however, the authorizations failed to include the name of the person, agency or organization to whom disclosure was made.
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Plan of Correction
Staff were in-serviced on the proper completeion of consent form on 9/11/10. Clinical Supervisor will review charts for compliance effective 10/11/1 and thereafter for a period of six (6)months. |
711.62(c)(2)(ii) LICENSURE Specific Information Disclosed
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:
(ii) The specific information disclosed.
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Observations
Based on survey results, interviews and patient records the non-hospital detoxification unit failed to obtain voluntary and informed consents to release information.
Findings:
On September 10, 2010 seven patient records were reviewed for compliance relative to informed and voluntary consents to release information. Three of seven records reviewed failed to include documentation of the specific information disclosed.
Client records # 1, 4 and 5 included signed consents to release information, however, the consents failed to include documentation of the specific information disclosed.
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Plan of Correction
Staff were in-serviced on the proper completion of consent form on 9/11/10. Clinical Superivsor will review charts for compliance effective 10/11/10 and thereafter for a period of six (6) months. |