INITIAL COMMENTS
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This report is a result of a complaint investigation conducted by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings, 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 and a plan of correction is due on August 25, 2008.
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Plan of Correction
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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 the complainant's treatment record on July 24, 2008, the facility failed to ensure that a urine specimen was obtained on at least a monthly basis. Specifically, there was no documentation that a urine drug screening was completed in June, 2008.
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Plan of Correction
A) CHANGES WHICH WILL BE IMPLEMENTED:
All monthly (minimum) outpatient urine drug screens will be randomly scheduled during the first three weeks of each month so as to reduce the risk of any client successfully evading this reqired urine drug screen. The Methadone Maintenance Program Director, with help from the administrative support staff, is responsible to ensure that all clients receive UDS every month (if outpatient) and every week (if IOP). This will be done with particular throughness due to revised threshold requirements for receipt of Sunday and other take home bottles.
B) TRAINING WHICH WILL BE PROVIDED:
The Methadone Maintenance Supervisor will continue to train other members of the administrative team to use monitoring tools effectively (such as ledgers, record books, etc.) to ensure that all clients receive all required urine drug screens within the required time frame and will emphasize that it will be impossible to successfully enact the revised THB policy without strict adherence to the regulatory requirement for at least monthly UDS for outpatient clients and weekly UDS for IOP clients.
C) THE TIME FRAME FOR IMPLEMENTATION:
Identification of all clients who will be required to lose all existing THB was begun on September 11, 2008. This new policy will be fully implemented by October 5th, 2008. |
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 the review of the complainant's treatment record on July 24, 2008 and information provided by the complainant and information obtained through staff interviews on July 24, 2008, the facility failed to transfer the patient within 7 days of the patient's request for a transfer. The facility did not transfer the patient until outside entities were involved.
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Plan of Correction
A) CHANGES WHICH WILL BE IMPLEMENTED:
All clients who request a transfer to another program will be given top priority by all KHMMP staff to ensure that they are transferred within the seven (7) days time frame mandated by regulation 715.20, and all efforts to enable this transfer to happen will be documented by all staff involved through the use of Non-Billable Progress Notes in the client's record. The Administrative staff (Supervisor, Senior Secretary, and Intake Secretary) will continue to carefully review all of the paperwork received for new admissions, transfer in and out, discharges and follow-up so as to ensure that all required communication and documentation have been completed in the proper time frame.
B) TRAINING WHICH WILL BE PROVIDED:
The Methadone Maintenance Supervisor will continue to train other members of the administrative team to use monitoring tools effectively (such as ledgers, record book, etc.) to ensure that all clients receive all requested transfers to another narcotic treatment program for continued maintenance, detoxification or another treatment activity, within 7 days of the request of the patient, as required by regulation 715.20.
C) THE TIME FRAME FOR IMPLEMENTATION:
Effective August 5th 2008. |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on the review of the complainants treatment record on July 24, 2008, the documentation ion the patient record was not accurate or complete. The patient record was missing the last two months of the patient's treatment documentation.
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Plan of Correction
A) CHANGES WHICH WILL BE IMPLEMENTED:
Every 2-4 weeks the counselors meet with the Clinical Supervisor, and at least three clients charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in services provided to ensure that the following requirements for individualized services are met:
1) 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which will be individual psychotherapy.
2) Additional psychotherapy as dictated by ongoing assessment of the patient. This means of supervision will also be used to ensure the documentation of services provided, and to develop a plan of correction to eliminate any deficiencies in such documentation of psychotherapy services provided to clients. These chart reviews will incude reviews of closed cases to ensure that follow-up information is included in the record for all discharged clients. Furthermore, staff training will be provided to all counselors to help them to become more organized, motivated and disciplined in their syle of providing psychotherapeutic services so as to help clietns to solve their problems and meet their needs within this framework for complience with all regulatory requirements.
B) TRAINING WHICH WILL BE PROVIDED:
As noted above, staff training will be provided to all counselors to help them to become more organized, motivated and disciplined in their style of providing psychotherapeutic services so as to help cliens to solve their problems and meet their needs within this framework for complienace with all regulatory requirments.
C) THE TIME FRAME FOR IMPLEMENTATION:
Effective August 5th 2008.
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