INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3-4, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center, was found to be not 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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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection, the facility failed to secure confidential client information.
A fax machine, located in an open cubicle in the waiting area of the facility, received several facsimile transmissions, containing client identifying information, while DDAP staff were conducting the physical plant inspection. This area was unattended by any facility staff, and the fax machine was accessible to any staff or clients. The facility director acknowledged that this area is left unattended and that the fax machine location was not secure for this reason.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
the fax machine has been relocated into a secure and locked office. This action will prevent client access to client identifying information received by fax. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to document a valid consent to release information for clients #1-14. The facility consent template states that the consent may only be revoked by notifying the therapist, case manager or doctor.
Client #1 was admitted on 6/19/18 and was an active client at the time of the licensing inspection.
Client #2 was admitted on 1/25/12 and was an active client at the time of the licensing inspection.
Client #3 was admitted on 12/11/17 and was an active client at the time of the licensing inspection.
Client #4 was admitted on 9/12/18 and was an active client at the time of the licensing inspection.
Client #5 was admitted on 1/18/18 and was an active client at the time of the licensing inspection.
Client #6 was admitted on 1/25/17 and was discharged on 9/26/18.
Client #7 was admitted on 7/23/15 and was discharged on 1/19/18.
Client #8 was admitted on 4/11/00 and was discharged on 2/7/18.
Client #9 was admitted on 2/6/15 and was discharged on 10/25/17.
Client #10 was admitted on 1/24/18 and was an active client at the time of the licensing inspection.
Client #11 was admitted on 1/9/18 and was an active client at the time of the licensing inspection.
Client #12 was admitted on 2/14/18 and was an active client at the time of the licensing inspection.
Client #13 was admitted on 12/21/17 and was an active client at the time of the licensing inspection.
Client #14 was admitted on 7/3/18 and was discharged on 9/12/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
the consent template has been revised immediately to state that the consent may be revoked "at any time by written or verbal request". Immediate.
effective Nov. 15 2018 the supervisor will ensure
all new and existing clients will sign the revised consent form reflecting the change stated above. The clinical supervisor will oversee the correction process and ensure all client records adhere to this standard. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
The facility failed to provide accurate admission and/or discharge dates in four of ten records submitted.
The admission and discharge dates on the facility discharge report did not correspond to the actual dates of admission and discharge in the actual records; this created a delay in ability to select appropriate records for review.
This information was reviewed with the facility during the licensing inspection.
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Plan of Correction
Jfk will provide a client admissions report from the Methasoft system. This report shows the date of admission which is also the first date the client is dosed by order of the physician. There will be coordination between the methasoft and carelogic systems to reflect the same and proper discharge date. The clinical supervisor will provide a training with staff to teach how this coordination will take place. The clinical supervisor is responsible for ensuring compliance. the staff training and the coordination between the two systems will occur 11/22/18 |
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
The facility failed to document that all clients received monthly urine screens.
Client #3 was admitted on 12/11/17 and was an active client at the time of the licensing inspection. There was no urine drug screen documented for August 2018.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
urine drug screens were obtained from client #3 on 8/7/18 and 8/22/18. However they were not uploaded into the system prior to the inspection. The procedure for preventing this from occurring again is 1)upon receipt lab report goes to on duty nurse for review.2) nurse gives results to clerk to upload on the same day as receipt.3)clerk will verify the upload against the list of active clients.4)nurse will review and confirm all clients were tested and uploaded into the system two days prior to the end of the month. The clinical supervisor is responsible for ensuring compliance with this procedure.
effective 11/15/18.
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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
The facility failed to document accurate information in the semi-annual dosage review.
Client #6 was admitted on 1/25/17 and was discharged on 9/26/18.
The semi-annual dose review, documented on 9/26/18, stated that methadone be continued at 15 mg, however #6 was administratively tapered and transferred out on 9/24/18; last dose was documented at 10 mg. on 9/24/18 06:59 am
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
on September 23,2018 the nurse printed an advance list of dosages for the physician. client #6 was in the midst of detox and transfer and last dose was on 9/24/18. On 9/26/18 the 6 month re-write orders were completed by the doctor who inadvertently relied on the 9/23 dosing list. the client #6 was already transferred out of the unit. All nurses have been instructed to only print dosing information on the day the physician is dosing.2)never pre print dosing information.3)physician will only use current daily information for re-writes. this policy has been put in writing and given to appropriate staff. The clinical supervisor will ensure compliance with the standard. The corrective action began on 10/19/18. |
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
The facility failed to document that all clients received the required counseling hours for clients #1, & 11-13.
Client #1 was admitted on 6/19/18 and was an active client at the time of the licensing inspection. The client received only 2 hours of counseling for September 2018.
Client #11 was admitted on 1/9/18 and was an active client at the time of the licensing inspection. The client received only 2 hours of counseling for June and July 2018.
Client #12 was admitted on 2/14/18 and was an active client at the time of the licensing inspection. The client received only 2 hours of counseling for August 2018.
Client #13 was admitted on 12/21/17 and was an active client at the time of the licensing inspection. The client received only .5 hours of counseling for March, April and June 2018; and received 2 hours per month for July and September 2018.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
a staff training will be held on October 30, 2018 to assist counselors to adhere to the requirement to provide a minimum of 2.5 hours of counseling per month. any issues that prevent staff from meeting this requirement will be identified and resolved. the clinical supervisor will ensure staff compliance via a review of staff service reports on a monthly basis. Effective 11/15/18 by the supervisor |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to update the treatment plan every 60 days in ten of fourteen client records reviewed.
Client #2 was admitted on 1/25/12 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 12/6/17; a treatment plan update was due by 2/6/18 but was not documented until 2/13/18; additionally, a treatment plan update was documented on 4/13/18; a treatment plan update was due by 6/13/18 but was not documented until 6/15/18.
Client #3 was admitted on 12/11/17 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 2/15/18; a treatment plan update was due by 4/15/18 but was not documented until 5/5/18. additionally, a treatment plan update was due by 7/5/18 but was not documented until 7/18/18.
Client #5 was admitted on 1/18/18 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was documented on 2/16/18; a treatment plan update was due by 4/16/18 but was not documented until 5/1/18; additionally, a treatment plan update was documented on 6/27/18; a treatment plan update was due by 8/27/18 but was not documented until 9/4/18.
Client #6 was admitted on 1/25/17 and was discharged on 9/26/18. A treatment plan update was documented on 1/19/18; a treatment plan update was due by 3/19/18 but was not documented until 3/27/18; additionally, a treatment plan update was documented on 4/30/18; a treatment plan update was due by 6/30/18 but was not documented until 7/11/18.
Client #8 was admitted on 4/11/00 and was discharged on 2/7/18. A treatment plan update was documented on 10/4/17; a treatment plan update was due by 12/4/17 but was not documented until 12/7/17.
Client #9 was admitted on 2/6/15 and was discharged on 10/25/17. A treatment plan update was documented on 8/23/17; a treatment plan update was due by 10/23/17 but was not documented.
Client #10 was admitted on 1/24/18 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 4/30/18; a treatment plan update was due by 6/30/18 but was not documented until 7/11/18.
Client #11 was admitted on 1/9/18 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 5/8/18; a treatment plan update was due by 7/8/18 but was not documented until 7/16/18; additionally, another update was due by 9/16/18 but was not documented until 10/2/18.
Client #12 was admitted on 2/14/18 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was documented on 3/2/18; a treatment plan update was due by 5/2/18 but was not documented until 5/21/18; additionally, a treatment plan update was due by 7/21/18 but was not documented until 8/2/18 and an update was due by 10/2/18 but was not documented at the time of the inspection.
Client #13 was admitted on 12/21/17 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was documented on 1/8/18; a treatment plan update was due by 3/8/18 but was not documented until 3/20/18; additionally, a treatment plan update was due by 5/20/18 but was not documented until 6/26/18 and an update was due by 8/26/18 but was not documented until 8/29/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
a staff training will be provided by the clinical supervisor to assist counselors to improve the timely documentation of treatment plan updates. As part of the training, counselors will receive a set of self assessment questions to be reviewed daily, which will serve as a reminder of this responsibility and assist them with timely documentation of treatment plan updates. The clinical supervisor will monitor compliance reviewing treatment plan Alerts in carelogic prior to the end of each month. The training will take place on 11/14/18. the procedure for ensuring the timeliness will occur by looking into each records alert system for incomplete documentation. the supervisor will preform this duty as part of supervision |