INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone / buprenorphine monitoring inspection conducted on August 21 - 23, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Eagleville 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.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
The facility failed to document a core curriculum in clinical supervision training was completed in one of four records reviewed on August 21, 2018.
Employee #17 was promoted to Clinical Coordinator on December 20, 2017. No documentation was available to show the employee functioned for two years as a supervisor in the provision of clinical services, or the employee completed a core curriculum in clinical supervision.
The findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the previous inspection on August 22-25, 2017.
|
Plan of Correction
The staff member who was promoted to Clinical Supervisor, referred to as Employee 17, attended the Clinical Supervision Training in Altoona PA from 8/27/18 - 8/31/18, thereby correcting this deficiency.
Director of Staff Development will audit all promotions to make sure all requirements are met for trainings as per policy and regulations. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
The facility failed to ensure each counselor met the qualifications for the position in one of three personnel records reviewed on August 21, 2018.
Personnel #5 was hired as a counselor on December 7, 2017, but does not meet the educational or experiential requirements for the position.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The staff member who was hired as an Evening Therapist, referred to as Personnel #5 who did not meet the qualifications for the position, has as of 8/23/18, been placed in the job title of Recovery Educator rather than a full time therapist title thereby correcting this deficiency.
Director of Human Resources will assure that staff hired in clinical positions have the credentials required for that position per job description and regulations. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
|
Observations
The facility failed to document the physician's face to face determination of current dependency on a narcotic drug in three of seven patient records reviewed on August 22, 2018. Patient records #1, #2, and #11 were missing documentation.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Chief of the Medical Staff will inform all admitting and attending physicians that a face to face determination of current opioid dependency is reflected in their documentation. This information will be written via email and verbally reported at the October Medical Staff meeting.
Quality Management will audit 15 records per month x 3 months to monitor that a face to face determination of current dependency of a narcotic drug occurred by a physician (or CRNP/PA after waiver is granted) and is appropriately documented. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
The facility failed to document a consult between the physician / physician extender conducting the patient examination and the physician determining the initial dose in three of seven patient records reviewed on August 22, 2018. Patient #1, #2, and #3 did not include documentation of the consult.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the previous inspection on August 22-25, 2017.
|
Plan of Correction
The Chief of the Medical Staff will inform all physicians via email of the requirement for consultations. A consult will be documented when the physician conducting the exam is different than the physician writing the initial order, and this consult will occur prior to determining the patient's initial dose and schedule. This directive will also be discussed and documented at the October Medical Staff Meeting.
Quality Management will audit 15 records per month x 3 months to monitor that the consult occurred between the prescribing physician and the admitting Licensed Independent Practitioner (Physician, CRNP,PA) and documentation was evident.
|