INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on July 15, 2024 through July 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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
|
704.12(a)(4)(i) LICENSURE Inpat. Hosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(4) Inpatient hospital treatment and rehabilitation (general, psychiatric or speciality hospital).
(i) Projects serving adult clients shall have one FTE counselor for every seven clients.
|
Observations
Based on a review of the project's Staffing Requirements Facility Summary Report, the project failed to ensure the inpatient hospital treatment and rehabilitation activity did not have more than one FTE counselor for every seven clients. At the time of the inspection, the project's Inpatient Hospital Treatment and Rehabilitation level of care had an FTE counselor/client ratio of 14:1. Based on the information provided in the staffing report, the overall calculation was as follows: 110 (active client hours) / 40 (hours of project work week) = 2.75 (FTE); then, 40/2.75 (total number of clients divided by FTE) = 14.545, which equals to the FTE client/counselor ratio of 14:1.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Counseling Services or Designee will ensure there is FTE primary care staff person available for every seven clients during primary care hours.
A copy of the schedule will be provided bi-weekly (from 07/19/2024 - 08/23/2024) for Leadership review to ensure
compliance and reviewed at the Leadership Meeting
|
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
Based on a review of patient records, the narcotic treatment program failed to have a narcotic treatment physician document a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug prior to admission for detoxification treatment and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment in two of eighteen applicable patient records reviewed.Patient # 21 was admitted to the Inpatient Non-Hospital Detoxification level of care on December 27, 2023 and was discharged on January 2, 2024. The face-to-face determination with the narcotic treatment physician was completed on December 27, 2023; however, there was no documentation indicating the patient was currently physiologically dependent upon a narcotic drug. Patient # 28 was admitted to the Inpatient Non-Hospital level of care on January 2, 2024 and was discharged on March 1, 2024. The face-to-face determination with the narcotic treatment physician was completed on December 27, 2023; however, there was no documentation indicating the patient was currently physiologically dependent and had been physiologically dependent upon a narcotic drug for at least 1 year prior to admission. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Prior to providing narcotic treatment the Admissions Department will obtain an informed, voluntary, written consent from the patient (upon admissions).
A MANDATORY field will be added to the History and Physical that will require the provider to mark yes or no to question "individual is currently physiologically dependent upon a narcotic drug". This will be completed by 9/20.
Monitoring an electronic review of randomly selected records of 10 per week from 9/20/24-10/20/24 to ensure the the field addressing current dependency on a narcotic is completed and will present the results at the December 2024 Quality Management Committee.
|
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent was administered to the patient in one of eighteen applicable patient records reviewed. Patient #2 was admitted into the Inpatient Hospital Detoxification level of care on September 25, 2023 and was discharged September 30, 2023. There was no documentation of an informed consent to treat in the record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Prior to providing narcotic treatment the Admissions Department will obtain an informed, voluntary, written consent from the patient (upon admissions) and provider and nursing will verify prior to administration of the first dose.
Monitoring electronic EMR of randomly selected records of 10 per week from 10/1/24 - 11/1/24 to ensure the informed consent is completed December 2024 Quality Management Committee.
|
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to maintain onsite a photograph of each patient, which is to include the patient's name and date of birth, in one of eighteen applicable patient records reviewed. Patient #15 was admitted to the Inpatient Hospital Treatment and Rehabilitation level of care on January 5, 2024 and was discharged on February 12, 2024. There was no photograph of the patient in the project's EMR system at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Photos will be taken upon admissions and the admissions supervisor will review charts to ensure compliance. If photos are not available on the chart when the patient arrives on the unit, the senior therapist will escort the patient back to admissions to have a picture taken.
Monitor an electronic review of randomly selected records 20 charts
from 07/19/2024 - 08/23/2024 to ensure the photo of the person is available and will present the results at the September 2024 Quality Management Committee.
|
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 patient records, the narcotic treatment program failed to complete a random, monthly urinalysis for each patient in one of eighteen patient records reviewed. Patient #14 was admitted into the Inpatient Hospital Treatment and Rehabilitation level of care on December 27, 2023 and was discharged on February 14, 2024. There was no documentation that a random urinalysis was conducted during the month of January 2024. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
This was not a patterned finding.
The Director Nursing is responsible for monitoring an electronic review of randomly selected records (20 charts)
from 07/19/2024 - 08/23/2024; to ensure an initial drug screening urinalysis is completed upon admissions and random urinalyses were completed thereafter.
Audit Results will be shared at the 09/2024 Quality Managment Committee.
|
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.
|
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 two of two applicable patient records reviewed. Patient # 20 was transferred in and admitted to the Inpatient Non-Hospital Detoxification level of care on December 13, 2023 and was discharged on December 18, 2023. There was no documentation in the record that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given. Patient # 22 was transferred in and admitted to the Inpatient Non-Hospital Detoxification level of care on January 4, 2024 and was discharged on January 9, 2024. There was no documentation in the record that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.This is a repeat citation from the August 11, 2023 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Admissions and the
Director of Nursing ensures compliance of po 5000.403 (Initial/Final Dose Form). The admitting individual will complete the first section of the Initial Methadone Dose form
by documenting the following actions:
- Provide the date to of contact
- Name of the Referring Clinic
- Address of Referring Clinic
- Fax No: of Referring Clinic
- Name of Admitted Patient
- Date of Admission to Eagleville
- Printed Name of Staff Completing the form
- Signature of the Staff Completing the form
Communication with Nursing Personnel will take place on or before 09/03/2024.
An audit of 10 Charts Per from 09/03/2024 - 10/15/2024.
This objective will be added to the 2024- 2025 QAPI (Quality Assurance Performance Improvement Plan) for quarterly observations and bi-annual metric reporting.
|
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
Based on an administrative review of the narcotic treatment program ' s unusual incident logs, the program failed to notify the Department within 48 hours of an incident involving complaints of physical, verbal, sexual, and/or emotional patient abuse. There was documentation of an incident involving a complaint of patient abuse on April 28, 2024; however, the incident was not reported to the Department until May 1, 2024. Additionally, there was documentation of an incident involving a complaint of patient abuse on May 14, 2024; however, the incident was not reported to the Department as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
EH had a change in staffing, the person typically, responsible for completing
the special incident reports left.
The Department manager was responsible for completing the forms. A new staff member has been hired and trained and and administrative assistant was hired to assist with ensuring that reports are entered timely. Quality will audit quarterly for compliance with this x 6 months ending on 3/16/25.
|
711.62(c)(2) LICENSURE Informed & Voluntary Consent
711.62. 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:
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven applicable client records reviewed.Client # 16 was admitted to the Inpatient Non-Hospital Detoxification level of care on July 10, 2024 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on July 10, 2024 and had an expiration date of July 10, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after July 10, 2024.Client # 17 was admitted to the Inpatient Non-Hospital Detoxification level of care on July 11, 2024 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on July 11, 2024 and had an expiration date of July 11, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after July 11, 2024.Client # 18 was admitted to the Inpatient Non-Hospital Detoxification level of care on July 11, 2024 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on July 11, 2024 and had an expiration date of July 11, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after July 11, 2024.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Due to a change in the EMR July 01, 2024
providing the opportunity for the user to select the incorrect time frame for the consent. The identified errors were corrected immediately and while inspectors were onsite. We corrected the deficient records at the time of the survey and have changed the form so that the date is one year from the time the form was signed unless the patient indicates another time frame
This selection has been removed.
Monitor an electronic review of randomly selected records of 10 per week from 07/19/2024 - 08/23/2024 to ensure informed consent form is accurate and complete and will present the results at the September 2024 Quality Management Committee.
|
711.62(c)(2)(i) LICENSURE Name of Person/agency/organization
711.62. 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:
(i) The name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in one of seven client records reviewed. Client # 16 was admitted to the Inpatient Non-Hospital Detoxification level of care on July 10, 2024 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the client on July 10, 2024; however, the release form did not include the name of the person, agency, or organization to whom the disclosure would be made. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
NetSmart is a newly implemented EMR
of July 01, 2024. The system provided the opportunity for the user to
select the incorrect time frame for the consent.
This selection has been removed.
The Director of Admissions is responsible for monitoring
an electronic review of randomly selected records of 10 per week from 07/19/2024 - 08/23/2024 to ensure the name of the person, agency, organization to whom disclosure is made and will present the results at the September 2024 Quality Management Committee.
|
711.53(c)(2)(i) LICENSURE Person/Agency/Org to Whom Disclosure Made
711.53. 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:
(i) The name of the person, agency, organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms in one of seven applicable client records reviewed. Client #24 was admitted to the Inpatient Non-Hospital level of care on June 6, 2024 and was still active at the time of the inspection. The release of information forms to an emergency contact and a referral source were signed by the client on June 6, 2024; however, both of the forms did not include the name of the person, agency, or organization to whom the disclosures would be made.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
NetSmart is a newly implemented EMR
of July 01, 2024. The incorrect form was e entered into the system.
The form has been corrected.
The Director of Admissions or Designee completed an electronic review of randomly selected records of 10 per week from 07/19/2024 - 08/23/2024 to ensure the name of the person, agency, organization to whom disclosure is made and will present the results at the September 2024
Quality Management Committee.
|
710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
|
Observations
Based on a review of patient records, the facility failed to keep patient records confidential in accordance with applicable Federal drug and alcohol regulations in one of eight applicable patient records reviewed. Federal regulation 42 CFR Part 2 requires a written consent to release information form, signed by the client, to include an explicit description of the substance use disorder information that may be disclosed. Patient #6 was admitted to the Inpatient Hospital Detox level of care on October 11, 2023 and was discharged on October 21, 2023. In the record, there was a client-signed release of information form to the funding source and the release form stated, "the specific information to be released is that necessary for the purpose of the disclosure," which is not an explicit description of the information to be disclosed. This is a repeat citation from the August 10, 2023 through August 11, 2023 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Admissions or Designee will complete weekly (10) chart audits
to observe compliance from 07/19/2024 through 08/23/2024
Prior to releasing any information, the Medical Records Department will
assure the release of information to the funding source form identifies the specific information to be released.
The Admissions Director or Designee
is responsible for this plan of correction and will present the results in the September 2024 Quality Management Committee
|
710.25(a) LICENSURE Notification and Termination
§ 710.25. Notification and termination.
(a) The director shall notify the patient, in writing, of a decision to involuntarily terminate the patient ' s treatment in the service. The notice shall include the reasons for termination.
|
Observations
Based on a review of patient records, the facility failed to notify the patient, in writing, of the facility's decision to involuntarily terminate the patient's treatment in one of one applicable patient record reviewed.Patient #8 was admitted to the Inpatient Hospital Detox level of care on September 15, 2023 and was involuntarily terminated on September 18, 2023. There was no documentation of the client receiving written notice of the termination in the record.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Patients/residents will be notified of discharge in writing of their discharge date from the unit and the type of discharge. Counseling has been re-educated and will document receipt of written notification.
Monitoring an electronic review of randomly selected records of 10 per week from 07/19/2024 - 08/23/2024 to ensure the involuntary discharge notification is documented in the chart will present the results at the September 2024 Quality Management Committee.
|
710.25(b) LICENSURE Notification and Termination
§ 710.25. Notification and termination.
(b) The patient shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of patient records, the facility failed to provide the patient an opportunity to request reconsideration of a decision terminating treatment in one of one applicable patient record reviewed.Patient #8 was admitted to the Inpatient Hospital Detox level of care on September 15, 2023 and was involuntarily terminated on September 18, 2023. There was no documentation of the client receiving an opportunity to request reconsideration of the termination in the record.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Patients/residents will be notified of discharge in writing of their discharge date from the unit and the type of discharge. A formal grievance form will be provided to the patient at the time he/she is notified of discharge. This meeting will be documented in the chart by counseling staff.
Monitoring an electronic review of randomly selected involuntary discharge records of 10 per month
from 9/1/24-10/1/24 to ensure grievance process is followed and documented and will present the results at the December 2024 Quality Management Committee.
|