INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 24, 2022 through October 25, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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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
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in one of three applicable personnel records reviewed.Employee # 3 was hired as a counselor on February 12, 2018. The personnel record documented 16 hours of training received during the training year reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/2/2022, the Director of Behavioral Health Services conducted an audit on all staff to assure they have the required number of training hours for the year by 12/31/2022. If they are deficient in training hours, staff were instructed to obtain the number of trainings hours still needed for the year before 12/15/2022.
In order to assure continued compliance, the Director of Behavioral Health Services will use this auditing process each year to assure staff have required the required number of training hours for the year.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to have hot water under pressure in all facility bathrooms. On October 25, 2022, at approximately 9:50 AM, there was no hot water in the first-floor patient bathroom. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An outside vendor installed a new water tank in the clients' restroom on the 1st floor on 11/9/2022. The clients' restroom now has hot water.
In order to assure continued compliance, the Assistant Director will check the clients' restroom water every Monday to assure there is hot water. The results of this weekly monitoring will be reported to the Performance Improvement Committee.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed. On October 25, 2022, at approximately 9:50 AM, a space heater was found in the nurse's station.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater in the nurse's station was removed from the clinic on 10/25/2022. The Director of Behavioral Health Services met with the Kensington Hospital Outpatient Treatment Program staff on 10/25/2022 to reiterate no space heaters are permitted at the clinic.
In order to assure continued compliance, the Security Guard will make daily rounds to assure there are no unauthorized space heaters in the Clinic. The results of this daily rounding will be reported to the Performance Improvement Committee.
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711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for not providing an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was submitted and approved by the Department for the October 21, 2021 and May 20, 2021 annual licensing inspections. Not providing an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was again found to be a deficiency in the October 24, 2022 through October 25, 2022 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Hospital Administration needed to make a change in management at the Outpatient Treatment Program, due to non-compliance with required duties. The Clinical Supervisor of the Outpatient Treatment Program was terminated in 4/8/2022 and a new Director of Behavioral Health Services was assigned to the Outpatient Treatment Program effective 4/12/2022. Also, there was a large turn-over rate of Counselors between 5/2021 and 9/2022, which led to the 2.5 hours of psychotherapy per month not achieving compliance.
In order to achieve compliance, the Director of Behavioral Health Services, audited the charts of each counselor on 10/27/2022 to determine which clients are in need of the 2.5 hours of psychotherapy per month. A meeting was held with the Counselors on 10/28/2022 to distribute their clients in need of this psychotherapy per month. Counselors were instructed to achieve the 2.5 hours per month of those clients immediately.
The Director will then perform chart reviews on those clients as well as any new client to treatment on a monthly basis. The results of these monthly reviews will be presented to the Performance Improvement Committee.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on an administrative review, the facility failed to ensure that narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients. The patient census during the week of June 13, 2022 to June 19, 2022 was 164, which required 17 physician hours; however, there were only 15 physician hours documented. The patient census during the week of July 4, 2022 to July 10, 2022 was 164, which required 17 physician hours; however, there were only 10.5 physician hours documented. The patient census during the week of July 25, 2022 to July 31, 2022 was 167, which required 17 physician hours; however, there were only 11.5 physician hours documented. This is a repeat citation from the October 21, 2021 annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A Narcotic Treatment Physician was hired on 8/1/2022 to work a total of 24 hours per week. This 24-hour weekly schedule currently accommodates the client census of 182. If and when the Program census increases past 240, the Narcotic Treatment Physician's hours will increase as well. Also on 10/26/2022, the Hospital assigned a back-up Narcotic Treatment Physician, to cover for the permanent physician when he is on vacation, etc.
In order to assure continued compliance, the number of Narcotic Treatment Physician weekly hours will be reviewed by the Director of Behavioral Health Services the beginning of each week to assure the physician is working at least 1 hour per week onsite for every ten (10) patients. The weekly monitoring results will be reported to the Performance Improvement Committee.
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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 a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in five of ten patient records reviewed.Patient # 1 was admitted on February 27, 2022 and was still active at the time of inspection. There was no documented drug screen urinalysis in the record for the month of September 2022.Patient # 2 was admitted on December 1, 2021 and was still active at the time of the inspection. There was no documented drug screen urinalysis in the record for the months of July 2022, August 2022 and September 2022.Patient # 3 was admitted on November 16, 2021 and was still active at the time of the inspection. There was no documented drug screen urinalysis in the record for the months of December 2021, January 2022, April 2022, July 2022, and September 2022.Patient # 6 was admitted on January 12, 1999 and was discharged on April 5, 2022. There was no documented drug screen urinalysis in the record for the month of January 2021.Patient # 9 was admitted on March 16, 2018 and was discharged on May 26, 2022. There was no documented drug screen urinalysis in the record for the months of December 2021 and January 2022.This is a repeat citation from the October 21, 2021 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services met with the Outpatient Treatment staff on 10/25/2022 to remind them to random urinalysis must be completed for each of their clients monthly.
In order to assure continue compliance, a monthly chart review will be conducted by the Assistant Director of Behavioral Health Services and those results will be reported to the Performance Improvement Committee.
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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 a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in three of five applicable patient records reviewed. Patient # 2 was admitted on December 1, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that there were no group and individual psychotherapy hours provided to the patient during the month of September 2022. Patient # 3 was admitted on November 16, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that there were no group and individual psychotherapy hours provided to the patient during the month of August 2022.Patient # 5 was admitted on November 11, 2021 and was discharged on May 17, 2022. The record of service and progress notes documented that there was 1.5 hours of group and individual psychotherapy hours provided to the patient during the month of March 2022. Additionally, there was 30 minutes of group and individual psychotherapy provided to the patient during the month of February 2022. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services met with the Outpatient Treatment Program staff on 10/25/2022 to remind them that any client in their first 2 years of treatment must have an average of 2.5 hours of psychotherapy per month.
In order to assure continued compliance, monthly chart reviews will be done by the Assistant Director of Behavioral Health Services to assure those clients in their first 2 years of treatment receive the 2.5 hours of psychotherapy per month. The results of this monthly monitoring will be reported to the Performance Improvement Committee.
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