INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on September 24 and 25, 2012, 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:
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documentation and the facility's policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan within the policy time frame.
The findings include:
The policy and procedure manual and administrative documentation was reviewed on September 24, 2012. The facility's policy identified the training year as January to December. The annual evaluation of the overall training plan due date is identified as year end. The administrative documentation of the annual evaluation for 2011 was dated September 21, 2012.
The findings were reviewed with the Project Director, Facility Director and clinical staff and were not disputed.
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Plan of Correction
The Annual Evaluation of employee training will be done annually by 12/31, monitored quarterly and assessed at the end of the calendar year.
The Director of Addiction Services is responsible for continued compliance. |
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 document the completion of 25 clock hours of annual training required for counselors in one of one personnel records reviewed.
The findings included:
Seven personnel records were reviewed on September 24, 2012. One personnel record was required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 3.
Employee # 3 was hired on July 12, 2010. The facility training year is from January through December. The training year for January 2011 to December 2011 was reviewed. Employee # 3 only completed 10 clock hours of annual training in 2011.
The findings were reviewed with the Project Director, Facility Director and clinical staff and were not disputed.
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Plan of Correction
Each clinical staff member will have their required 25 hours of training outlined in their approved annual training plan. These areas of training are listed in 704.11.
The Director of Addiction Services is responsible to assure continued compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation in two of four patient records reviewed. In addition, the facility failed to document a psychosocial evaluation that contained all components in one patient record.
The findings include:
Four patient records were reviewed on September 25, 2012. All records were reviewed for psychosocial evaluations. The facility failed to document a psychosocial evaluation in patient records #1 and 2. The facility failed to document all the components in the psychosocial evaluation in patient record # 4.
Patient # 1 was admitted on September 22, 2012. The psychosocial evaluation was not documented as of the date of the inspection.
Patient # 2 was admitted on September 21, 2012. The psychosocial evaluation was not documented as of the date of the inspection.
Patient # 4 was admitted on September 19, 2012, and discharged on September 24, 2012. The psychosocial evaluation provided a review of the patient history without an evaluation.
The findings were reviewed with the Facility Director who confirmed a psychosocial evaluation was due in the records. The Project Director, Facility Director and clinical staff did not dispute the findings.
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Plan of Correction
A revised Biopsychosocial History form has been developed, along with a structured biopsychosocial assessment form.
The Performance Improvement Coordaintor will assure continued compliance by conducting radom monthly chart reviews. |
709.63(a)(2) LICENSURE D & A support plan
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(2) Drug and alcohol support plan.
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Observations
Based on a review of patient records, the facility failed to document a drug and alcohol support plan that was individualized in two of four patient records reviewed.
The findings include:
Four patient records were reviewed on September 25, 2012. All records were reviewed for drug and alcohol support plans. The facility failed to document a support plan that was individualized in patient records #2 and 3.
Patient # 2 was admitted on September 21, 2012. The drug and alcohol support plan was not individualized.
Patient # 3 was admitted on September 24, 2012. The drug and alcohol support plan was not individualized.
The findings were reviewed with the Project Director, Facility Director and clinical staff and were not disputed.
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Plan of Correction
Subsequent to a Staff Meeting on 10/25/12 with detox counselors, a revision was made within the paperwork and a section documenting drug and alcohol support planning was added as a separate document.
In order to assure continued compliance, the Director of Addiction Services will audit charts upon discharge. |
709.63(a)(3) LICENSURE Progress notes
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(3) Progress notes.
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Observations
Based on a review of patient records, the facility failed to document progress notes in three of four patient records reviewed.
The findings include:
Four patient records were reviewed on September 25, 2012. All records were reviewed for progress notes. The facility failed to document progress notes in patient records #1, 2, and 4.
Patient # 1 was admitted on September 22, 2012. The patient record contained no progress notes as of the date of the inspection.
Patient # 2 was admitted on September 21, 2012. The patient record contained no progress notes as of the date of the inspection.
Patient # 4 was admitted on September 19, 2012, and discharged on September 24, 2012. The patient record contained no progress notes.
The findings were reviewed with the Project Director, Facility Director and clinical staff and were not disputed.
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Plan of Correction
After each patient contact/encounter, a progress note will be documented by the clinician in DAP form.
In order to assure continued compliance, the Lead Counselor will audit charts for progress notes on a daily basis. |
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
Based on the review of patient records, the facility failed to document a narcotic treatment physician face-to-face determination in one of four records.
The findings include:
Four patient records were reviewed on September 25, 2012. All records were reviewed for narcotic treatment physician face-to-face documentation. The facility failed to document a narcotic treatment physician face-to-face in patient record #3..
Patient # 3 was admitted on September 24, 2012, and received a narcotic agent. The physical exam was completed by the Certified Registered Nurse Practitioner (CRNP) on September 24, 2012, and an order for the narcotic agent was documented by the CRNP. The physical exam was signed by the narcotic treatment physician on September 25, 2012. The record had no documentation of a consult with the narcotic treatment physician by the CRNP.
The findings were reviewed with the Project Director, Facility Director and clinical staff and were not disputed.
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Plan of Correction
The Medical Director of Addiction Services or the Physician on-call shall document patient's need for methadone assisted detoxification. The physician will be responsible for assessment and documentation for justifying the patient's need for methadone detoxification.
The Performance Improvement Coordinator will conduct random monthly chart reviews to assure continued compliance. |
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 patient records, the facility failed to provide aftercare referrals based upon the status of the patient in two of four records.
The findings include:
Four patient records were reviewed on September 25, 2012. Two records were reviewed for aftercare plans. The facility failed to document aftercare referrals based on upon the status of the patient in patient records #2 and 4.
Patient # 2 was admitted on September 21, 2012. The patient record contained an aftercare plan for a referral to a narcotic treatment program.
Patient # 4 was admitted on September 19, 2012, and discharged on September 24, 2012. The patient record contained an aftercare plan for a referral to a narcotic treatment program.
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.
The findings were reviewed with the Project Director, Facility Director and clinical staff. The Facility Director disputed the aftercare plan as a referral.
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Plan of Correction
Any patient presenting for opiate detoxification will be asked at time of admission if they are considering methadone maintenance as aftercare. If the the patient is, the Medical Director and appropriate staff will be notified immediately.
A transfer is arranged for Methadone Maintenance Treatment.
The Director of Addiction Services will assure continued compliance by implementing a form to be used by the Admissions Staff in which the patient declines methadone maintenance as a form of aftercare.
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