INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and narcotic monitoring conducted on September 22-23, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of administrative paperwork and an interview with the facility director, the facility failed to submit or subsequently provide an overall training plan for training year 2016.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Kensington Hospital will ensure that an overall training plan for the facility. The Director of Behavioral Health Services will work with the Chief Executive Officer to complete the overall training plan for the facility. The overall training plan will be completed at the beginning of the training calendar. Compliance with the overall training plan will be monitored by the Director of Behavioral Health Services. The program will be in compliance by 11/4/16. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an observation during the physical plant inspection conducted on September 22, 2016, the facility failed to ensure that exits from the facility were unobstructed.
The pathway leading from the rear group room exit to the alley behind the building was cluttered with metal and debris.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All obstructions were removed by the Kensington Hospital maintenance staff on 10/10/16. Compliance with clear pathways will be monitored by the Director of Environmental Services. The facility is in compliance as of 10/10/16. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee #6's personnel record, the facility failed to document the date of the fire extinguisher training which was to be completed upon hire. Employee #6 was hired April 18, 2016.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All Kensington Hospital employees receive training in the use of fire extinguishers. Employees #3 and #4 received the training but the training was documented incorrectly. The omission of the date was brought to the attention of the project administrative assistant on 9/20/16. The project administrative assistant will monitor the training forms for compliance. The facility is in compliance as of 10/18/16. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill record from October 2015 through August 2016 and an interview with the facility staff, the facility failed to document the exit route used during monthly fire drills.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The fire drill logs were amended to include the exit route used during the monthly fire drill. The amended fire drill log went into use on 10/3/16. The fire drill log will be monitored by the Director of Environmental Services. The facility is in compliance as of 10/3/16. |
717.18(a)(2) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(2) Employment services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for the provision of employment services.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Director of Behavioral Health Services will connect with local legal services and develop referral agreements between Kensington Hospital and the employment service. These agreements will updated every two years. Compliance with referral agreements will be monitored by the facility Administrative Assistant. The facility will be in compliance by 12/30/16. |
715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for the provision of adult educational services.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Director of Behavioral Health Services will connect with local educational services and develop referral agreements between Kensington Hospital and the educational service. These agreements will updated every two years. Compliance with referral agreements will be monitored by the facility Administrative Assistant. The facility will be in compliance by 12/30/16. |
715.18(b) LICENSURE Rehabilitative services
(b) A patient shall also have the opportunity to access legal services.
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Observations
Based on a review of administrative paperwork, a list of the facility's service agreements and a conversation with facility staff, the facility failed to provide or document agreements for access to legal services.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Director of Behavioral Health Services will connect with local legal services and develop referral agreements between Kensington Hospital and the legal service. These agreements will updated every two years. Compliance with referral agreements will be monitored by the facility Administrative Assistant. The facility will be in compliance by 12/30/16. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Base on a review of client records conducted on September 22-23, 2016 the facility failed to document a case consult for client #7.
Client #7 was admitted on 1/12/1999 and was still active at the time of the inspection. The last case consult was documented on 1/27/2015.
This information was reviewed with the acility staff during the licensing inspection.
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Plan of Correction
Counselors received training about follow-up on 10/21/16 from the Director of Behavioral Health Services. Counselors understand that case consultation must occur every 90 days during the patient's first year in treatment and at least annually after one year of treatment. The case consultation form is part of the patient chart. The Director of Behavioral Health Services will monitor the charts for compliance. The Director of Behavioral Health Services will provide supervision and training regarding case consultation as needed. The Director of Behavioral Health Services will monitor the record for compliance with case consultation. Case consultation for patient #7 will occur on 10/31/16. The facility will be in compliance by 10/31/16. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Base on a review of client records conducted on September 22-23, 2016 the facility failed to document follow up information in client records #10 and 14.
Client #10 was admitted on 10/24/13 and was discharged on 10/8/15.
Client #14 was admitted on 4/11/08 and was discharged on 8/15/16.
This information was reviewed with the acility staff during the licensing inspection.
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Plan of Correction
Counselors received training about follow-up on 10/21/16 from the Director of Behavioral Health Services. Counselors understand that follow-up must occur with every discharged patient within seven days of discharge. The follow-up forms are part of the patient chart. The Director of Behavioral Health Services will monitor the charts for compliance. The Director of Behavioral Health Services will provide supervision and training regarding follow-up as needed. The Director of Behavioral Health Services will monitor the record compliance with follow-up. The Director of Behavioral Health Services will ensure that follow up is conducted for Patients # 10 and #14 on 10/31/16. The facility will be in compliance by 10/31/16. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of client records conducted on September 22-23, 2016, the facility failed to document or was late documenting a comprehensive treatment.
Client #2 was admitted on 2/2/16 and was discharged on 7/7/16. As of the date of the licensing inspection the facility failed to document a comprehensive treatment plan.
Client #4 was admitted on 4/8/16 and was still an active client as of the date of the licensing inspection. A preliminary treatment plan was documented on 4/8/16 and the comprehensive treatment plan was not documented until 6/21/16, 2 months later. The facility failed to document the comprehensive treatment plan during intake.
Client #9 was admitted on 5/17/16 and was still an active client as of the date of the licensing inspection. A preliminary treatment plan was documented on 5/17/16 and the comprehensive treatment plan was not documented until 7/12/16, almost 2 months later. The facility failed to document the comprehensive treatment plan during intake.
Client #13 was admitted on 5/23/16 and was discharged on 8/9/16. A preliminary treatment plan was documented on 5/23/16 and the comprehensive treatment plan was not documented until 7/29/16, 2 months later. The facility failed to document the comprehensive treatment plan during intake.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors received training about comprehensive treatment plans on 10/21/16 from the Director of Behavioral Health Services. Counselors understand that comprehensive treatment plans must be completed within 30 days of admission to the program. The comprehensive treatment plan is part of the patient chart. The Director of Behavioral Health Services will monitor the charts for compliance with completing comprehensive treatment plans within the 30-day timeframe. The Director of Behavioral Health Services will provide supervision and training regarding comprehensive treatment plans as needed. The Director of Behavioral Health Services will monitor the record for compliance with comprehensive treatment plans. The facility will be in compliance by 10/28/16.
Client #2 is discharged on 7/7/2016.
Client #4 will have the treatment plan updated every 60 days.
Client #9 will have the treatment plan updated every 60 days.
Client #13 was discharged on 8/9/2016. |
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 conducted on September 22-23, 2016, the facility failed to update the comprehensive treatment plan every 60 days in four of sixteen client records.
Client #4 was admitted on 4/8/16 and was still an active client as of the date of the licensing inspection. A comprehensive treatment plan was documented on 6/21/16, however, the treatment plan update was not documented until 8/23/16.
Client #5 was admitted on 1/21/16 and was still an active client as of the date of the licensing inspection. A treatment plan update was documented on 5/20/16, however, the next treatment plan update was not documented until 8/10/16.
Client #7 was admitted on 1/12/99 and was still an active client as of the date of the licensing inspection. A treatment plan update was documented on 6/30/16, however, the next treatment plan update was not documented until 9/15/16.
Client #9 was admitted on 5/17/16 and was still an active client as of the date of the licensing inspection. A comprehensive treatment plan was documented on 7/12/16, however, the treatment plan update was not documented as of the date of the inspection.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors received training about treatment plan updates on 10/21/16 from the Director of Behavioral Health Services. Counselors understand that treatment plan updates must be completed every 60 days after completion of the comprehensive treatment plan. The treatment plan update is part of the patient chart. The Director of Behavioral Health Services will monitor the charts for compliance with completing treatment plan updates within the 60-day timeframe. The Director of Behavioral Health Services will provide supervision and training regarding treatment plan updates as needed. The Director of Behavioral Health Services will monitor the record for compliance with treatment plan updates. The facility will be in compliance by 10/28/16.
Client #4 will have the treatment plan updated every 60 days.
Client #5 will have the treatment plan updated every 60 days.
Client #7 will have the treatment plan updated every 60 days.
Client #9 will have the treatment plan updated every 60 days.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records on September 22-23, 2016, the facility failed to document an informed and voluntary consent in the following client records.
Client #2 was admitted on 2/2/2016 and was discharged on 7/7/2016. The facility allowed for the release of the clients urine results to a government agency, which exceeded 4 PA Code 255.5. The consent to release was dated for 4/25/16. Additionally, a consent to release form to a family member dated 2/2/16 did not have the date of the client's signature.
Client #4 was admitted on 4/8/2016 and was still an active client at the time of the inspection. The facility allowed for the release of the clients urine results and for the release of the client's appointment dates and times of those appointments, to an government agency, which exceeded 4 PA Code 255.5. The consent to releases were dated for 8/25/16. Additionally, two letters one dated 4/15/16 and the other dated 4/18/16 for the client's probation officer were found in the record documenting the disclosure of the client's appointment times, which exceeded 4 PA Code 255.5.
Client #5 was admitted on 1/21/2016 and was still an active client at the time of the inspection. The facility failed to document what was being release on a consent to release form dated 8/15/16 for a treatment provider. Additionally, the facility failed also failed to document on a consent to release dated 3/31/16 the agency/person to whom the information was to be released. Lastly, there were two faxes one sent out 2/27/16 and the other fax had no date that had identifying information about the client. The facility failed to have consent to release forms for those two agencies.
Client #7 was admitted on 1/12/1999 and was still an active client at the time of the inspection. The facility failed to document what was being release on a consent to release form dated 3/10/16 for a treatment provider. Additionally, the facility failed also failed to document on a consent to release dated 2/5/16 the agency/person to whom the information was to be released.
Client #8 was admitted on 6/24/16 and was still an active client at the time of the inspection. The facility failed to document what was being release on a consent to release form dated 7/11/16 for a treatment provider.
Client #11 was admitted on 1/26/2012 and was discharged on 2/26/2016. Three consent to release information forms, two to funding sources and one to a transportation company, were not updated after they expired on 1/25/2015.
Client #12 was admitted on 9/16/2016 and was discharged on 9/21/2016. Three consent to release forms to other treatment providers dated 1/26/16, did not indicate what information was to be released.
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselors received training about confidentiality and the procedure for completing releases of information on 10/21/16 from the Director of Behavioral Health Services. Counselors were also trained in what information can be released depending on the type of institution the information is released to. DDAP Confidentiality training will be scheduled when it is available locally. The Director of Behavioral Health Services will monitor the charts for compliance. Any further compliance issues will be address by the Director of Behavioral Health Services. The facility will be in compliance as of 11/3/16.
Client #2 was discharged on 7/7/2016. The authorizations automatically terminated 30 days after discharge.
Client #4 authorizations were terminated 11/3/2016. Client #4 is currently in 3C level of care. New compliant releases will be signed upon the client's return to OP.
Client #5 authorizations were terminated on 11/3/2016. New compliant releases will be signed when needed.
Client #7 authorizations were terminated on 11/3/2016. New compliant releases will be signed when needed.
Client #8 authorization was terminated on 11/3/2016. New compliant releases will be signed when needed.
Client #11 was discharged on 2/26/2016.
Client #12 was discharged on 9/21/2016. |