INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on September 12, 2024 through September 13, 2024 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 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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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain an onsite photograph of each patient which is to include the patient's name and birth date in seven of twenty-one applicable patient records reviewed.
Patient # 3 was admitted to the inpatient hospital activity on September 5, 2024 and was still active at the time of the inspection. There was no onsite photograph of the patient documented in the record at the time of the inspection.
Patient # 7 was admitted to the inpatient hospital activity on December 20, 2023 and was discharged on January 31, 2024. There was no onsite photograph of the patient documented in the record at the time of the inspection.
Patient # 8 was admitted to the inpatient non-hospital activity on January 25, 2024 and was discharged on February 14, 2024. There was no onsite photograph of the patient documented in the record during the patient's treatment episode.
Patient # 12 was admitted to the inpatient non-hospital detoxification activity on May 9, 2024 and was discharged on May 13, 2024. There was no onsite photograph of the patient documented in the record during the patient's treatment episode.
Patient # 13 was admitted to the inpatient non-hospital detoxification activity on June 17, 2024 and was discharged on June 21, 2024. There was no onsite photograph of the patient documented in the record during the patient's treatment episode.
Patient # 22 was admitted to the inpatient non-hospital activity on May 13, 2024 and was discharged on May 27, 2024. There was no onsite photograph of the patient documented in the record during the patient's treatment episode.
Patient # 23 was admitted to the inpatient non-hospital detoxification activity on June 21, 2024 and was discharged on July 17, 2024. There was no onsite photograph of the patient documented in the record during the patient's treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Behavioral Health Services, in-serviced the new Admissions Intake Worker on 9/17/2024 that all patients must have a photograph on the medical record which is to also include the patient's name and birth date.
In order to assure continued compliance, the Performance Improvement Coordinator will initiate a Performance Improvement Study to review medical records on a monthly basis to assure all patients admitted to Kensington Hospital's Behavioral Health Unit has a photograph which also includes the patient's name and date of birth.
The results of these monthly studies will be reported to the Performance Improvement Committee on a quarterly basis. |
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 an initial drug-screening urinalysis for each prospective patient in one of twenty-one applicable patient records reviewed.
Patient # 7 was admitted to the inpatient hospital activity on December 20, 2023 and was discharged on January 31, 2024. The patient received the first dose of medication on December 20, 2023; however. there was no documentation that the initial drug-screening urinalysis was completed prior to the initial dose.
This is a repeat citation from the September 27, 2023 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 met with and in-serviced the Admissions Intake Staff as well as the Laboratory Technician that the initial drug screen urinalysis must be on the medical record for all patients admitted to Kensington Hospital.
The Hospital's laboratory now has the capability of sending lab results directly to the patient's medical records within 24 hours. The Laboratory Technician will check the following day to assure the initial drug screen urinalysis is on the medical record.
In order to assure continued compliance, the Performance Improvement Coordinator will study medical records on a monthly basis to assure the patient's initial drug screen urinalysis is on the patient's chart.
The results of this monthly study is then reported to the Performance Improvement Committee on a quarterly basis. |
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 one of one applicable patient record reviewed.
Patient # 13 was transferred in and admitted to the inpatient non-hospital detoxification activity on June 17, 2024 and was discharged on June 21, 2024. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the patient ' s date of admission and date the initial dose was given.
This is a repeat citation from the September 27, 2023 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 met and in-serviced the Counseling Staff on 9/19/2024 that counselors must notify the transferring narcotic treatment program in writing the date of the admission of the patient and the date of the initial dose given to the patient.
This particular counselor was counselled individually on 9/19/2024 as well and a written warning placed in the employee's personnel file.
In order to assure compliance, the Performance Improvement Coordinator will study medical records on a monthly basis to monitor that counselors are notifying the transferring narcotic treatment program in writing the date of the admission of the patient and the date of the initial dose given to the patient.
The results will be forwarded to the Performance Improvement Committee on a quarterly basis.
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711.52(c)(2) LICENSURE Type/Frequency of TX
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of five applicable client records reviewed.
Patient # 20 was admitted to the inpatient non-hospital activity on December 21, 2023 and was discharged on January 3, 2024. The individual treatment plan was completed on December 22, 2023 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 21 was admitted to the inpatient non-hospital activity on December 10, 2023 and was discharged on January 3, 2024. The individual treatment plan was completed on December 11, 2023 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 22 was admitted to the inpatient non-hospital activity on May 13, 2024 and was discharged on May 27, 2024. The individual treatment plan was completed on May 9, 2024 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 23 was admitted to the inpatient non-hospital activity on June 21, 2024 and was discharged on July 17, 2024. The individual treatment plan was completed on June 18, 2024 and was missing the type and frequency of treatment services to be provided to the patient.
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 and in-serviced the Counseling Staff on 9/19/2024 on this deficiency. The Counselors were instructed they must document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
The Performance Improvement Coordinator will initiate a PI Study to monitor charts on a monthly basis to assure the counselors are documenting the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
The results of this study will be presented to the Hospital's Performance Improvement Committee on a quarterly basis. |
710.22(c) LICENSURE Patient Management Services
§ 710.22. Patient management services.
(c) The service staff shall develop a written patient follow-up policy.
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Observations
Based on a review of patient records, the facility failed to follow their written patient follow-up policy in one of one applicable patient records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified after a patient is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Patient #1 was admitted to the inpatient hospital detoxification activity on December 14, 2023 and was discharged against medical advice on December 15, 2023. There was no documentation in the record indicating the emergency contact was notified of the patient's discharge as of the date of the 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 and in-serviced the Counseling Staff on 9/19/2024 that the patient's emergency contact must be contacted when a patient leaves against medical advice. This notification must be documented in the patient's medical chart.
To assure continued compliance, the Performance Improvement Coordinator will monitor medical records on a monthly basis to assure counselors are notifying the patient's emergency contact when the patient leaves against medical advice and documents the notification in the medical record.
The results of this monthly monitoring will be forwarded to the Performance Improvement Committee at the Committee's quarterly meetings. |
710.41(b)(3) LICENSURE Admission - Treatment and Rehabilitation
§ 710.41. Admission-treatment and rehabilitation.
(b) Admission procedures shall include documentation of the following:
(3) Initial treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to document, as part of their admission process, an initial treatment and rehabilitation plan in one of one applicable patient record reviewed.
Patient # 6 was admitted to the inpatient hospital activity on August 1, 2024 and was discharged on August 15, 2024. There was no initial treatment and rehabilitation plan documented in the record at the time of the 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 deficiency with the Counseling staff on 9/19/2024. The Counseling staff were in-serviced that they must document an initial treatment and rehabilitation plan on all patient admitted to Kensington Hospital's Behavioral Health unit.
The Performance Improvement Coordinator will study medical charts on a monthly basis to be sure the counselors are, indeed, completing and documenting an initial treatment and rehabilitation plan.
The results of this monthly study will be presented to the Performance Improvement Committee at their quarterly meetings. |
710.42(b)(2) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(b) An individual treatment and rehabilitation plan shall be developed with each patient. This plan shall include, but not be limited to, written documentation of the following:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of patient records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six of six applicable patient records reviewed.
Patient # 3 was admitted to the inpatient hospital activity on September 5, 2024 and was active at the time of the inspection. The individual treatment plan was completed on September 6, 2024 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 4 was admitted to the inpatient hospital activity on August 21, 2024 and was active at the time of the inspection. The individual treatment plan was completed on August 21, 2024 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 5 was admitted to the inpatient hospital activity on August 20, 2024 and was active at the time of the inspection. The individual treatment plan was completed on August 23, 2024 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 7 was admitted to the inpatient hospital activity on December 20, 2023 and was discharged on January 31, 2024. The individual treatment plan was completed on December 22, 2023 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 8 was admitted to the inpatient non-hospital activity on January 25, 2024 and was discharged on February 14, 2024. The individual treatment plan was completed on January 26, 2024 and was missing the type and frequency of treatment services to be provided to the patient.
Patient # 9 was admitted to the inpatient hospital activity on January 22, 2024 and was discharged on January 24, 2024. The individual treatment plan was completed on January 22, 2024 and was missing the type and frequency of treatment services to be provided to the patient.
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 and in-serviced the Counseling staff on 9/19/2024 on this deficiency. The Counseling staff were instructed they must document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
The Performance Improvement Coordinator will initiate a Performance Improvement Study to monitor charts on a monthly basis to assure the counselor are documenting the type and frequency of treatment on the individual treatment and rehabilitation plan.
The results of this monthly monitoring will be reported to the Performance Improvement Committee on a quarterly basis.
The deficiency can not be corrected for those active clients have since discharged from the hospital. |
710.42(c) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(c) Treatment and rehabilitation plans shall be reviewed and updated at least every 15 days.
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Observations
Based on a review of patient records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every fifteen days in two of two applicable patient records reviewed.
Patient # 5 was admitted to the inpatient hospital activity on August 20, 2024 and was active at the time of the inspection. The individual treatment plan was completed on August 23, 2024 and the first update was due no later than September 7 ,2024; however, the update was not completed as of the date of the inspection.
Patient # 7 was admitted to the inpatient hospital activity on December 22, 2024 and was discharged on January 31, 2024. The individual treatment plan was completed on December 22, 2024 and the first update was due no later than January 6, 2024; however, the update was not completed prior to discharge.
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 and in-serviced the Counseling staff on 9/19/2024 that Treatment & Rehabilitation Plans must be reviewed and updated every 15 days.
In order to assure continued compliance, the Performance Improvement Coordinator will study medical records on a monthly basis to ensure counselors are reviewing and updating the Treatment & Rehabilitation Plans every 15 days.
The results of the monthly studies will be reported to the Hospital Performance Improvement Committee on a quarterly basis.
The deficiency can not be corrected as those patients have since discharged from the Hospital.
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