INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 11, 2023 through October 12, 2023 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of two applicable personnel records reviewed.
Employee #5 was hired as a counselor on February 28, 2022 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than February 28, 2023; however, there was no documentation of completion of TB/STD training at the time of inspection.
Employee #8 was hired as a registrar on April 19, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than April 19, 2023; however, there was no documentation of completion of TB/STD training at the time of 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 two (2) employees and mandated them to complete the 4 hour TB/STD training no later than 11/15/2023.
In order to assure continued compliance, all new hires will now obtain the required HIV/AIDS and TB/STD training the first week of hire.
The Director of Behavioral Health Services will monitor all new hires to assure the required HIV/AIDS and TB/STD training is obtained within the 1st week of hire.
The results of this monitoring will be reported to the Human Resources Coordinator (as needed) and the Performance Improvement Committee on a quarterly basis.
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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 May 20, 2021, October 21, 2021, and October 25, 2022 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 11, 2023 through October 12, 2023 licensing inspection.
A plan of correction for obtaining a random drug screen urinalysis at least monthly was submitted and approved by the Department for the May 20, 2021, October 21, 2021, and October 25, 2022 annual licensing inspections. Not obtaining a random drug screen urinalysis at least monthly was again found to be a deficiency in the October 11, 2023 through October 12, 2023 licensing inspection.
This is a repeat citation from the October 25, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the repeat citations for the following DDAP requirements:
1) An average of 2.5 hours of psychotherapy per month is required for those patients in their first 2 years of treatment
2) A random drug screen urinalysis must be obtained at least monthly.
The Director of Behavioral Health Services from 2021/2022 was terminated and a new Director of Behavioral Health Services was hired 4/2022.
In order to assist the current Director of Behavioral Health Services, an Assistant Director of Behavioral Health Services, was hired 10/24/2023.
The Assistant Director of Behavioral Health will closely monitor the operation of the Outpatient Treatment Program which will include closely monitoring the two (2) deficiencies cited above, by conducting audits of medical records on a monthly basis.
The Assistant Director of Behavioral Health Services will report the monthly results from the chart reviews to the Performance Improvement Committee on a quarterly basis.
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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
Based on a review of patient records, the facility failed to maintain in the record verification of the individual's identity, including name, address, date of birth, emergency contact and other identifying data in two of four applicable patient records reviewed.
Patient #8 was admitted on February 16, 2023 and was discharged on May 24, 2023. There was no documentation in the patient record that the patient's identity was verified prior to the administration of an agent.
Patient # 10 was admitted on August 30, 2023 and was active at the time of inspection. There was no documentation in the patient record that the patient's identity was verified prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services provided an in-service training on 10/23/2023 to the Intake Worker and the Outpatient Treatment counselors that a patient's identity must be verified prior to the administration of a narcotic agent.
The Intake worker will take a copy of the patient's identification at time of intake. If the patient does not have identification, the intake worker will then verify the patient's identity through the insurance company and maintain that in the patient's medical record.
In order to assure continue compliance, the Director of Behavioral Health Services will conduct monthly chart reviews to assure the patient's identify was verified prior to the administration of a narcotic agent.
The results from the monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to document, within 3 months after termination of pregnancy, an evaluation of the patient's treatment status into the patient's record and state whether the patient should remain in comprehensive maintenance treatment or receive detoxification treatment in one of one applicable patient records reviewed.
Patient #5 was admitted on September 27, 2016 and was active at the time of inspection. The patient gave birth at the end of October 2022, and the evaluation of the patient's treatment status, was due no later than the end of January 2023; however, the evaluation was not completed at the time of inspection.
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 Narcotic Treatment Physician on 10/19/2023 to review this DDAP finding. The Narcotic Treatment Physician is aware of the requirement to document within three (3) months after termination of pregnancy, an evaluation of the patient's treatment status into the medical record and state whether the patient should remain in comprehensive maintenance treatment or receive detoxification treatment.
The Director of Behavioral Health will audit records of any termination of pregnancy to assure the Narcotic Treatment Physician is documenting an evaluation of the patient's treatment status and is stating whether the patient should remain in comprehensive maintenance treatment or receive detoxification treatment.
The results of the monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis for at least a six (6) month period. |
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 six of ten patient records reviewed.
Patient #1 was admitted on October 29, 2018 and was discharged on May 8, 2023. There was no documented drug screen urinalysis, in the record, for the month of April 2023.
Patient #2 was admitted on March 14, 2017 and was discharged on April 17, 2023. There was no documented drug screen urinalysis, in the record, for the months of November 2022 through March 2023.
Patient #4 was admitted on September 6, 2018 and was discharged on April 6, 2023. There was no documented drug screen urinalysis, in the record, for the month of March 2023.
Patient #6 was admitted on September 1, 2020 and was discharged on September 11, 2023. There was no documented drug screen urinalysis, in the record, for the month of May 2023.
Patient #7 was admitted on September 28, 2022 and was discharged on June 30, 2023. There was no documented drug screen urinalysis, in the record, for the months of December 2022 and April 2023.
Patient #9 was admitted on March 2, 2023 and was active at the time of inspection. There was no documented drug screen urinalysis, in the record, for the month of July 2023.
This is a repeat citation from the May 20, 2021, October 21, 2021 and October 25, 2022 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 conducted an educational in-service to the outpatient Counseling staff that all clients must have a random urinalysis completed on a monthly basis. The in-service was held on 10/17/2023.
In order to assure continued compliance, the Director of Behavioral Health will conduct monthly chart reviews to assure a random urinalysis is done on all clients on a monthly basis.
The results of the monthly monitoring will be reported to the Performance Improvement Committee quarterly for at least six (6) months. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician reviewed the dosage levels at least twice a year, with each review occurring at least 2 months apart in one of eight applicable patient records reviewed.
Patient #5 was admitted on September 27, 2016 and was active at the time of inspection. A dosage level review was completed by a narcotic treatment physician on October 7, 2022. There was no documentation, in the patient record, of a second dosage level review at the time of inspection.
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 Narcotic Treatment Physician on 10/19/2023 to review the DDAP finding. The Narcotic Treatment Physician was instructed to conduct a review of clients' dosage levels at least twice a year with each review occurring at least 2 months apart from each other. One review will be conducted in January and the next review will be conducted in July.
In order to assure continued compliance, the Director of Behavioral Health Services will conduct medical chart in January and then again in July to assure the clients' dosage levels were reviewed by the Narcotic Treatment Physician.
The results from the January and July monitoring will be reported to the Performance Improvement Committee at the quarterly meeting in March and then again in September. The monitoring will continue for at least 6 months. |
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 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, in one of four applicable patient records reviewed.
Patient #7 was admitted on September 28, 2022 and was discharged on June 30, 2023. The record of service and progress notes documented that there was 32 minutes of individual psychotherapy for the month of March 2023.
This is a repeat citation from the May 20, 2021, October 21, 2021 and October 25, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services reviewed this citation with the Counseling staff in detail on 10/18/2023. The Director re-educated the Counselors that all clients in their first 2 years of treatment, must have an average of 2.5 hours of psychotherapy per month (1 hour of which shall be individual psychotherapy). The Director also mandated the counselor must provide this 2.5 hours of psychotherapy mid-month in order to capture the required hours.
In order to assure the continued compliance, the Director of Behavioral Health Services will audit medical charts monthly and report those monthly findings to the Performance Improvement Committee on a quarterly basis for at least six (6) months.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 each patient an average of 1 hour of group or individual psychotherapy every 2 months, after 4 years in treatment, in one of five applicable patient records reviewed.
Patient #5 was admitted on September 27, 2016 and was active at the time of inspection. The record of service and progress notes documented in average of 30 minutes of psychotherapy for the months of June and July 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services provided an education in-service with the Outpatient Treatment Program Counselors on 10/19/2023 to review this DDAP requirement.
For patients in treatment after 4 years, the counselors were instructed to provide each patient with an average of 1 hour of group or individual psychotherapy every 2 months.
In order to assure compliance, the Director of Behavioral Health Services will review records monthly on patients in treatment after 4 years to assure the counselors are providing the 1 hour of group or individual psychotherapy every 2 months.
The results from this monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient in one of two applicable patient records reviewed.
Patient #6 was admitted on September 1, 2020 and was transferred out on September 11, 2023. The patient record did not document that the receiving narcotic treatment program was notified of the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/18/2023, the Director of Behavioral Health Services provided an educational in-service to the outpatient counselors that when a patient is transferred, the patient file must include the following information:
Admission date, medical & psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient and shall also include the written consent of the patient.
The Director of Behavioral Health Services will then audit medical charts monthly to assure this information is included in the transfer file of the patient.
The results of the monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis for at least six (6) months. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in two of two applicable patient records reviewed.
Patient #9 was admitted on March 2, 2023 and was active at the time of inspection. The patient record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #10 was admitted on August 30, 2023 and was active at the time of inspection. The patient record did not document that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As part of the educational session provided to the outpatient counselors by the Director of Behavioral Health Services on 10/18/2023, the counselors were instructed to document in writing that they notified the transferring narcotic treatment program of the patient's date of admission and the date of the initial dose of methadone that was given to the patient.
In order to assure continued compliance, the Director of Behavioral Health Services will audit medical records monthly to assure the counselors are documenting the patient's date of admission and date of the initial dosage of methadone that was given.
The results from the monthly monitoring will be reported to the Performance Improvement Committee for at least six (6) months. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure that the counselor completed an annual evaluation of each patient's status that is to be reviewed, dated and signed by the medical director, in four of five applicable patient records reviewed.
Patient #2 was admitted on March 14, 2017 and was discharged on April 17, 2023. The annual evaluation of the patient ' s status was completed by the counselor on March 30, 2023; however, it was not reviewed, dated, and signed by the medical director.
Patient #3 was admitted on December 14, 2017 and was discharged on April 17, 2023. The annual evaluation of the patient ' s status was completed by the counselor on December 9, 2022; however, it was not reviewed, dated, and signed by the medical director.
Patient #5 was admitted on September 27, 216 and was active at the time of inspection. The annual evaluation of the patient ' s status was completed on September 30, 2021 and the next was due no later than September 30, 2022 and September 30, 2023; however, there was no annual evaluation documented in the patient record at the time of inspection.
Patient #6 was admitted on September 1, 2020 and was discharged on September 11, 2023. The annual evaluation of the patient's status was completed by the counselor on September 7, 2023; however, it was not reviewed, dated, and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/16/2023, the Director of Behavioral Health Services in-serviced the Counseling Staff and the Medical Director of the Program of the following requirements:
1) The counselor must complete an annual evaluation of each patient's status.
2) The Medical Director of the Outpatient Treatment Program will then review, sign and date the annual evaluation.
In order to assure continue compliance, the Director of Behavioral Health Services will conduct monthly chart reviews to assure:
1) The counselor is completing an annual evaluation of each patient's status and;
2) The Medical Director is reviewing, signing and dating the annual evaluation.
The results from the monitoring monitoring will be reported to the Performance Improvement Committee for at least six (6) months. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to assure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in seven of nine applicable client records reviewed.
Client #1 was admitted on October 29, 2018 and was discharged on May 8, 2023. A treatment plan update was completed on February 6, 2023, and the next update was due no later than April 8, 2023; however, the update was not completed prior to discharge.
Client #4 was admitted on September 6, 2018 and was discharged on April 6, 2023. A treatment plan update was completed on December 27, 2022, and the next update was due no later than February 27, 2023; however, the update was not completed prior to discharge.
Client #5 was admitted on September 27, 2016 and was active at the time of inspection. A treatment plan update was completed on February 23, 2023, and the next update was due no later than April 25, 2023; however, the update was completed on June 29, 2023. Additionally, the next treatment plan update was due no later than August 29, 2023; however, the update was completed on September 7, 2023.
Client #6 was admitted on September 1, 2020 and was discharged on September 11, 2023. A treatment plan update was completed on June 15, 2023, and the next update was due no later than August 15, 2023; however, the update was completed on August 25, 2023.
Client #7 was admitted on September 28, 2022 and was discharged on June 30, 2023. A treatment plan update was completed on December 16, 2022, and the next update was due no later than February 16, 2022; however, the update was completed on February 28, 2023. Additionally, a treatment plan update was completed on April 19, 2023, and the next update was due no later than June 19, 2023; however, the update was not completed prior to discharge.
Client #8 was admitted on February 16, 2023 and was discharged on May 24, 2023. The individual treatment and rehabilitation plan was completed on February 20, 2023, and the first treatment plan update was due no later than April 22, 2023; however, the update was completed on May 3, 2023.
Client #9 was admitted on March 2, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on March 2, 2023, and the first treatment plan update was due no later than May 2, 2023; however, the update was completed on July 14, 2023
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/19/2023, the Director of Behavioral Health Services met with the Outpatient Counselors to educate them on the DDAP requirement that Treatment and Rehabilitation Plans must be reviewed and updated every 60 days.
In order to assure continued compliance the Director of Behavioral Health Services will conduct chart reviews monthly to assure the counselors are reviewing and updating the Treatment and Rehabilitation plans every 60 days.
The findings from the monthly review will be reported to the Performance Improvement Committee for at least 6 months.
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