INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 5-6, 2014 by staff from the Division of Drug and Alcohol 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to have a written individual training plan for each employee in five of six personnel records reviewed.
The findings include:
The facility's SRFSR and six personnel records were reviewed for documentation of a written individual training plan. The facility failed to ensure that employees # 4, 5, 6, 7 and 8 had an individual training plan.
Employee # 4 was hired as the Medical Director on July 25, 2001. Personnel record # 4 did not include documentation of an individual training plan as of August 6, 2014.
Employee # 5 was hired as a Physician on September 8, 2011. Personnel record # 5 did not include documentation of an individual training plan as of August 6, 2014.
Employee # 6 was hired as the Nursing Director in June 1972. Personnel record # 6 did not include documentation of an individual training plan as of August 6, 2014.
Employee # 7 was hired as the Assistant Director of Nursing on October 27, 1986. Personnel record # 7 did not include documentation of an individual training plan as of August 6, 2014.
Employee # 8 was hired as a Licensed Practical Nurse on August 29, 2011. Personnel record # 8 did not include documentation of an individual training plan as of August 6, 2014.
The findings were confirmed by the facility director on August 6, 2014.
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Plan of Correction
The program will ensure that each staff member has an individual training plan. The Director of Behavioral Health Services will complete training plans with employees in the Behavioral Health Department. The Director of Nursing will complete training plans with employees in the Nursing Department. The Medical Director will complete training plans with the program physicians. The program will be in compliance by October 17, 2014. All training plans will be updated in January 2015 for the 2015 training year. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that hot food was served at or above 140 F.
The findings include:
A physical plant inspection was conducted on August 5, 2014. The Licensing Specialist asked to see a food serving temperature log during the inspection. A food serving temperature log was not presented for review; therefore, the facility lacked documentation to verify that hot food at the facility had been served at or above 140 F.
The findings were confirmed during an interview with the cook on August 5, 2014.
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Plan of Correction
Food service staff are equipped with thermometers and check temperatures to measure the temperature of hot food. To ensure that hot food is cooked to the proper temperature, the Cook will maintain a log of food temperatures for every meal daily. To ensure that hot food is held at 140 degrees Fahrenheit or higher, the Director of Food Service will maintain a log of food temperatures in the program area at the time of service one time weekly. To make sure the deficiency does not recur, the logs will be monitored by the Director of Food Service and the Director of Behavioral Health Services. The program will be in compliance on September 15, 2014. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation of the patient in three of twelve records reviewed.
The findings include:
Twelve patient records requiring documentation of a psychosocial evaluation were reviewed from August 5, 2014 to August 6, 2014. The facility failed to a document psychosocial evaluation in patient records # 2, 7, and 8.
Patient # 2 was admitted March 6, 2014 and discharged March 11, 2014. The psychosocial evaluation was due March 7, 2014. However, patient record # 2 did not include documentation of a psychosocial evaluation as of August 6, 2014.
Patient # 7 was admitted February 27, 2014 and discharged March 3, 2014. The psychosocial evaluation was due February 28, 2014. However, patient record # 7 did not include documentation of a psychosocial evaluation as of August 6, 2014.
Patient # 8 was admitted March 7, 2014 and discharged March 12, 2014. The psychosocial evaluation was due March 8, 2014. However, patient record # 8 did not include documentation of a psychosocial evaluation as of August 6, 2014.
The findings were confirmed by the facility director on August 6, 2014.
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Plan of Correction
Prior to the start of the new Director of Behavioral Health Services on 3/31/2014, counselors were not completing the evaluation sections of the psychosocial history and evaluation. The current Director of Behavioral Health Services provided training and supervision to the counselors in regards to psychosocial evaluations. Recent charts contain psychosocial evaluations that are in compliance with 715.23(b)(15). The Director of Behavioral Health Services will continue to provide supervision to counselors and check charts for compliance. |