INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on April 7 and 8, 2008 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 not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on May 5, 2008.
|
Plan of Correction
|
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
|
Observations
Based on the review of 13 patient records, the facility failed to, with patient consent, contact the previous narcotic treatment facility, identified by the patient upon admission, to obtain the patient's prior treatment history. Specifically, this was noted in one of one patient record, # 7.
|
Plan of Correction
A) The Administrative staff (Supervisor, Senior Secretary and Intake Secretary) will meet every week, beginning the first week of May, 2008, to carefully review all of the paperwork received for new admissions, transfers in and out, discharges and follow-up so as to ensure that all required communication and documentation have been completed in the proper time frame.
B) Formal training should not be necessary for this change to happen, but clearer communication and documentation, and any on the job staff training required, will be carried out by the Program Director and among the Administrative team, every week as needed.
C) The Methadone Maintenance Supervisor is responsible for ensuring that all Admissions, Transfers, Discharges and related documentation are carried out according to professional, ethical and regulatory standards consistently and completely.
D) Implementation of this change began on May 1st, 2008, and will continue as a matter of standard operating procedure every week hereafter.
|
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
Based on a review of patient records and written consent to release information forms, it was determined that the facility failed to fully identify the permitted information that needed to be released to the funding sources, but limited the information to presence in treatment. Specifically, this was noted in patient records # 4, 7, 8. In addition, patient records # 2 (Parkside) and 5 (Family Center) were transferred without a completed consent to release information signed by the patient.
|
Plan of Correction
A) The Intake Secretary had been too cautious in checking which information will be released, and will, henceforth, check all five boxes concerning relase of information about participation in treatment, the nature of the project, prognosis, progress and relapse, rather than only the box concerning presence in treatment.
B) Ongoing training will be provided about confidentiality requirements, restrictions and also when and what information may be comminicated and to whom and how without violating rules or regulations.
C) The Methadone Maintenance Supervisor is responsible for ensuring that all rules, regulations and procedures concerning confidentiality are adhered to completely and consistently.
D) Implementation of this change began on April 9th, 2008, immediately after the site visit. |
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.
|
Observations
Based on a review of 13 patient records, the facility failed to ensure that monthly random urine drug screens were obtained for two patients, # 1 (missing March 2008) and # 4, (last documented drug screen was July 2007). An initial urine drug screen was not completed for a transfer-in patient (# 8), admitted March 7, 2008.
|
Plan of Correction
PLAN OF CORRECTION:
(A)CHANGES WHICH WILL BE IMPLEMENTED: All monthly (minimum) outpatient urine drug screens will be randomly scheduled during the first three weeks of each month so as to reduce the risk of any client successfully evading this required urine drug screen..
(B)TRAINING WHICH WILL BE PROVIDED: The Methadone Maintenance Supervisor will continue to train other members of the administrative team to use monitoring tools effectively (such as ledgers, record books, etc.) to ensure that all clients receive all required urine drug screens within the required time frame.
(D)THE TIME FRAME FOR IMPLEMENTATION (30-60 DAYS): Effective May 1st, 2008
|
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.
|
Observations
Based on the review of 13 patient records, the facility failed to ensure a medication dose review was done at least twice annually for four patient records reviewed, # 1, last review documented was in 2006; # 2, last two documented reviews were 11/2005 and 02/2007; # 3, last two documented reviews were in 05/06 and 04/07; and # 4, last two documented reviews were in 10/06 and 07/07.
|
Plan of Correction
A) Changes which will be implemented: One medication dose review will be scheduled along with annual evaluation of client progress at time of the annual physical exam. Other medical dose reviews will be scheduled apporximately six months before, and six months after, the annual physical exam. A ledger will be used to ensure that all required dose reviews are scheduled and completely in the proper time frame.
B) Training which will be provided: The Methadone Maintenance Supervisor will continue to train other members of the administrative team to use monitoring tools effectively (such as ledgers, record books, etc.) to ensure that all clients receive all required medication dose reviews.
C) Supervisor who will impletent & monitor: The methadone maintenance supervosr is responsible for insuring that all rules, regulations and procedures concerning twice annually dose reviews are adhered to completely and consistently.
D) The time frame for implementation: Effective May 1st, 2008. |
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.
|
Observations
Based on a review of 13 patient records, the facility failed to ensure that the required components of the patient file was transferred to the receiving facility for patient #5.
|
Plan of Correction
(A)CHANGES WHICH WILL BE IMPLEMENTED: The Administrative staff (Supervisor, Senior Secretary and Intake Secretary) will meet every week, beginning the first week of May, 2008, to carefully review all of the paperwork received for new admissions, transfers in and out, discharges and follow-up so as to ensure that all required communication and documentation have been completed in the proper time frame.
(B) TRAINING WHICH WILL BE PROVIDED: Formal training to ensure that this change will happen will be carried out by the Program Director, and among the Administrative team, every week as needed. Counselors will also be instructed, and reminded as often as necessary (by the Administrative staff), what forms of communication and documentation are required to be in full compliance with all state laws and regulations.
(C) SUPERVISOR WHO WILL IMPLEMENT & MONITOR: The Methadone Maintenance Supervisor is responsible for ensuring that all Admissions, Transfers, Discharges and related documentation are carried out according to professional, ethical and regulatory standards ? consistently and completely. The Senior Secretary and the Secretary assist him with fulfilling this responsibility and duty.
(D)THE TIME FRAME FOR IMPLEMENTATION (30-60 DAYS): Implementation of this change began on May 1st, 2008, and will continue as a matter of standard operating procedure every week hereafter.
|
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
|
Observations
Based on a review of 13 patient records, the facility failed to document what materials were sent to the receiving facilities for patient records # 2 and 3.
|
Plan of Correction
(A)CHANGES WHICH WILL BE IMPLEMENTED: The Administrative staff (Supervisor, Senior Secretary and Intake Secretary) will meet every week, beginning the first week of May, 2008, to carefully review all of the paperwork received for new admissions, transfers in and out, discharges and follow-up so as to ensure that all required communication and documentation have been completed in the proper time frame. This will include ensuring that documentation of materials sent to receiving facilities is included in the patient record, in the proper section of the record.
(B) TRAINING WHICH WILL BE PROVIDED: Formal training to ensure that this change will happen will be carried out by the Program Director, and among the Administrative team, every week as needed. Counselors will also be instructed, and reminded as often as necessary (by the Administrative staff), what forms of communication and documentation are required to be in full compliance with all state laws and regulations. As noted above, this will include ensuring that documentation of materials sent to receiving facilities is included in the patient record, in the proper section of the record.
(C) SUPERVISOR WHO WILL IMPLEMENT & MONITOR: The Methadone Maintenance Supervisor is responsible for ensuring that all Admissions, Transfers, Discharges and related documentation are carried out according to professional, ethical and regulatory standards ? consistently and completely. The Senior Secretary and the Secretary assist him with fulfilling this responsibility and duty.
(D)THE TIME FRAME FOR IMPLEMENTATION (30-60 DAYS): Implementation of this change began on May 1st, 2008, and will continue as a matter of standard operating procedure every week hereafter.
|
715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
|
Observations
Based on a review of 13 patient records, the facility failed to ensure that a complete medical history was collected for four of four patient records reviewed, # 6, 7, 8 and 10. The medical histories failed to include the family medical history and the patient's symptoms and illnesses.
|
Plan of Correction
A) Changes which will be implemented: The narcotic treatment physician will complete all sections of the medical history without leaving any section blank or sufficiently detailed in the information provided by the client/patient and interpreted by the narcotic treatment physician.
B) Training which will be provided: The narcotic treatment physician will receive training on mandatory medical requiremtns by a trainer approved by the Pennsylvania Department of Health, within 60 days of taking on this responsibility and duty (by June 7th, 2008).
C) Supervisor who will implement & monitor: The narcotic treatment physician is supervised by the medical director of Kensington Hospital and is also accountable to the Chief Executive Officer of Kensington Hospital.
D) The time frame for implementation: June 7th, 2008. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
|
Observations
Based on the review of 13 patient records, there was no documentation the facility had completed a tuberculosis Mantoux test for five of six patients reviewed, records # 6, 7, 10, 12 & 13. In addition, reports for blood serology for Syphilis were missing for three of seven patient records reviewed, # 10, 12 and 13.
|
Plan of Correction
(A)CHANGES WHICH WILL BE IMPLEMENTED: No client will be accepted to the program or assigned to a counselor until the facility has received proof of a recent tuberculosis Mantoux test from a transferring facility or has been given a PPD by the Kensington Hospital medical staff.
(B)TRAINING WHICH WILL BE PROVIDED: The Narcotic Treatment Physician will receive training on mandatory medical requirements by a trainer approved by the Pennsylvania Department of Health, within 60 days of taking on this responsibility and duty (by June 7th, 2008). He will also ensure that all of the nursing and other staff (such as members of the Administrative staff, such as the Clinical Supervisor, Senior Secretary and Secretary) are trained of the need to ensure complete of these tests within the first two weeks of treatment. The nursing staff will also be trained by the Narcotic Treatment Physician to ensure that all required blood serology tests for Syphilis are included in patient records as well. Both of these requirements are clearly indicated in the program policy and procedures manual.
(C)SUPERVISOR WHO WILL IMPLEMENT & MONITOR: The narcotic treatment physician is supervised by the Medical Director of Kensington Hospital and is also accountable to the Chief Executive Officer of Kensington Hospital.
(D)THE TIME FRAME FOR IMPLEMENTATION (30-60 DAYS): (by June 7th, 2008)
|
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on review of 13 patient records, the facility failed to provide an evaluative assessment of the historical data obtained that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in five of five records reviewed, # 7, 8, 10, 11, 13. In addition, patient record # 12 was missing an evaluation.
|
Plan of Correction
(A)CHANGES WHICH WILL BE IMPLEMENTED: All counseling staff will be trained to improve their evaluative assessments of the problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment, etc., and their overall impressions of the client's motivation, attitudes, behavior, thoughts, feelings, experiences and the like. Training guides and work books will be used for this purpose, as well as trainers (from inside and outside of Kensington Hospital) so that skill in this area of professional practice may be continuously improved and refined.
(B)TRAINING WHICH WILL BE PROVIDED: (See above). Training will be provided both outside of the hospital from expert trainers in this area, and within the hospital by the Clinical Supervisor. Other training opportunities will also be sought by the Methadone Maintenance Supervisor so as to ensure improvement in this area of evaluative assessment..
(C)SUPERVISOR WHO WILL IMPLEMENT & MONITOR: The Methadone Maintenance Supervisor will ensure that continuous improvement is made in this area, beginning no later than June 1st, 2008, and will continue until the desired level of excellence and professionalism is achieved, even if this requires more than the goal of 60 days..
(D)THE TIME FRAME FOR IMPLEMENTATION (60 DAYS): Training in this area will began on the week of May 19th, 2008, and changes in evaluative work will be implemented from June 1st, 2008 through July 31st, 2008.
|
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on a review of 13 patient records, the facility failed to document a complete discharge summary in four of four patient records, specifically # 2, 3, 4, and 5. The discharge summary in records # 2 and 3 failed to document the patient's reason for treatment and the services offered. Records # 4 and 5 failed to include a discharge summary after the patient was discharged.
|
Plan of Correction
(A)CHANGES WHICH WILL BE IMPLEMENTED: The Administrative staff (Supervisor, Senior Secretary and Intake Secretary) will meet every week, beginning the first week of May, 2008, to carefully review all of the paperwork received for new admissions, transfers in and out, discharges and follow-up so as to ensure that all required communication and documentation have been completed in the proper time frame.
(B) TRAINING WHICH WILL BE PROVIDED: Formal training will be implanted to ensure that this change happens in a timely manner, especially to produce clearer communication and documentation. Any on the job staff training which is needed will be carried out by the Program Director, with and among the Administrative team, every week as needed.
(C) SUPERVISOR WHO WILL IMPLEMENT & MONITOR: The Methadone Maintenance Supervisor is responsible for ensuring that all Admissions, Transfers, Discharges and related documentation are carried out according to professional, ethical and regulatory standards ? consistently and completely.
(D)THE TIME FRAME FOR IMPLEMENTATION (30-60 DAYS): Implementation of this change began on May 1st, 2008, and will continue as a matter of standard operating procedure every week hereafter with the goal of completing the needed changes by July 1st, 2008.
|
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
|
Observations
Based on a review of 13 patient records, the facility failed to provide documentation of follow up for one of one patient record reviewed, specifically # 4.
|
Plan of Correction
(A)CHANGES WHICH WILL BE IMPLEMENTED: The Administrative staff (Supervisor, Senior Secretary and Intake Secretary) will meet every week, beginning the first week of May, 2008, to carefully review all of the paperwork received for new admissions, transfers in and out, discharges and follow-up so as to ensure that all required communication and documentation have been completed in the proper time frame.
(B) TRAINING WHICH WILL BE PROVIDED: Formal training will be implanted to ensure that this change happens in a timely manner, especially to produce clearer communication and documentation. Any on the job staff training which is needed will be carried out by the Program Director, with and among the Administrative team, every week as needed.
(C) SUPERVISOR WHO WILL IMPLEMENT & MONITOR: The Methadone Maintenance Supervisor is responsible for ensuring that all Admissions, Transfers, Discharges and Follow-up related documentation are carried out according to professional, ethical and regulatory standards ? consistently and completely.
(D)THE TIME FRAME FOR IMPLEMENTATION (30-60 DAYS): Implementation of this change began on May 1st, 2008, and will continue as a matter of standard operating procedure every week hereafter with the goal of completing the needed changes by July 1st, 2008.
|