INITIAL COMMENTS
|
This report is a result of an onsite licensure renewal and methadone & buprenorphine monitoring inspection. The inspection was conducted on August 22 - 25, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite 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 the inspection:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Twenty-five personnel records were reviewed on August 22-23, 2016. The facility did not provide documentation of the required 6 hours HIV/AIDS and 4 hours TB/STD training in eight of twenty-five personnel records reviewed.
Employee # 1, a counselor, was hired August 6, 2015. The facility failed to ensure employee # 1 completed HIV/AIDS training by August 6, 2016.
Employee #7, a counselor, was hired August 6, 2015. The facility failed to ensure employee #7 completed HIV/AIDS and TB/STD training by August 6, 2016.
Employee #20, a counselor, was hired September 18, 2014. The facility failed to ensure employee #20 completed HIV/AIDS and TB/STD training by September 18, 2015.
Employee #21, a counselor, was hired August 4, 2014. The facility failed to ensure employee #21 completed HIV/AIDS training by August 4, 2015.
Employee #22, a counselor, was hired June 26, 2014. The facility failed to ensure employee #22 completed HIV/AIDS and TB/STD training by June 26, 2015.
Employee #23, a counselor, was hired June 11, 2015. The facility failed to ensure that employee #23 completed HIV/AIDS and TB/STD training by June 11, 2016.
Employee #24, a counselor, was hired November 13, 2014. The facility failed to ensure that employee #24 completed HIV/AIDS and TB/STD training by November 13, 2015.
Employee #25, a counselor, was hired October 30, 2014. The facility failed to ensure that employee #25 completed HIV/AIDS and TB/STD training by October 30, 2015.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #1 ? Staff is scheduled for training on 10/28/16
Employee #7 ? Staff has resigned
Employee #20 - Staff is scheduled for training on 10/28/16 and 11/3/16
Employee #21 ? Staff has resigned
Employee #22 - Staff is scheduled for training on 10/28/16 and 11/3/16
Employee #23 - Staff is scheduled for training on 10/28/16 and 11/3/16
Employee #24 ? Staff has resigned
Employee #25 - Staff is scheduled for training on 10/28/16 and 11/3/16.
Director of Staff Development will continue to follow up. We also plan to utilize the curriculum from DDAP to begin training internally so we can get staff trained much more rapidly. We plan to begin this by 11/1 for Confidentiality and January 1 for Basic HIV and TB/STD/Hep. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
A physical plant inspection was conducted on August 25, 2016. The facility failed to keep the grounds safe, and sanitary and in good repair at all times.
1. 2nd floor Levy - Broken glass ceiling light in the group room.
2. 2nd floor Levy - Room 204 had a hole in the wall.
3. 2nd floor Louchheim - Multipurpose room had stains in the carpet.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The following items were corrected by our Director of Plant Operations:
The broken glass in the ceiling light on Levy 2 was repaired on 9-22-16.
The hole in the wall on Levy 2 Room 204 was repaired the date of inspection, August 25, 2016.
The carpet in the multipurpose room on LH2 was cleaned on August 29, 2016.
Compliance to be assured by monthly environmental rounds team. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
The physical plant inspection was conducted on August 25, 2016 around 9 am. During the inspection, it was observed one restroom located on the third floor, in Louchheim, did not have a mirror.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A mirror was added to the restroom on LH3 on 8-31-16 by the Director of Plant Operations. Continuing compliance to be assured by monthly environmental rounds conducted by team. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
During the physical plant inspection, which was conducted around 9am on August 25, 2016, it was observed that the last time the fire extinguishers were inspected was July 2015. The staff was interviewed around the same time of the physical plant inspection and explained the fire extinguishers were inspected but failed to update the service tag on the fire extinguishers.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
There was one expired fire extinguisher and one about to expire that were found in the Arnstein building. They were replaced immediately the day of the survey on 8-25-16 by the Director of Plant Operations. Compliance to be assured with monthly environmental rounds by team. |
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 current dependency for one of two buprenorphine patients during the patient record review inspection completed on August 22 - 25, 2016.
Patient #4 was admitted to treatment on June 7, 2016 and discharged on June 17, 2016. Current dependency was not documented prior to the initial dose given on June 8, 2016.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Dr. Michael Frost with review the need for documentation of current opiate dependence through historical information, physical findings, and the urine drug screen at the next executive medical staff meeting on October 12, 2016. Medical staff will be expected to complete evidence of current dependency prior to first dose. This will be monitored through monthly chart reviews. |
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 conducting the patient exam and the physician determining the initial dose in three of four patient records reviewed during the inspection on August 22 - 25, 2016.
Patient # 1 was admitted to treatment on April 30, 2016. An exam was completed on 4-30-2016, the initial dose of methadone was given on 5-1-2016.
Patient # 2 was admitted to treatment on May 9, 2016. An exam was completed on 5-9-2016, the initial dose of methadone was given on 5-10-2016.
Patient # 4 was admitted to treatment on June 7, 2016. An exam was completed on 6-7-2016, the initial dose of buprenorphine was given on 6-8-2016.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Currently, the admitting physician and prescribing narcotic treatment physician complete a verbal consult prior to determining the patient's initial dose and schedule. In the future, that verbal consult will be documented in the EMR by the prescribing narcotic treatment physician. Dr. Michael Frost will discuss the importance of this with medical staff at the next Executive Medical Staff meeting on 10-12-16. Compliance with be monitored through monthly chart reviews. |
711.64(b) LICENSURE Record Keeping System
711.64. Data Collection System.
(b) A drug and alcohol data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
|
Observations
During the August 22- 25, 2016 inspection, the facility failed to provide a recordkeeping system that allows for the efficient retrieval of data.
Patient lists provided by the facility did not indicate accurate information regarding pregnancy, or levels of care.
The facility ' s electronic medical record system was utilized to review patient records. Licensing specialists and facility staff were initially locked out of system on August 23 & 24, and were delayed in their review of the client records. Once access was achieved, two to four facility staff assisted licensing specialists in navigating the system, but the system still did not allow for the efficient retrieval of client record documentation.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Director of IT has reviewed the current system and made the following corrective action to be in effect 9-30-16.
In the future Eagleville staff responsible for assisting the licensing specialists will verify system access with the temporary system credentials to be utilized by these licensing specials, before the scheduled licensing review date. Any issues with the temporary system credentials will be corrected by the Eagleville Hospital IT department before the start of the licensure survey. These outdated and incorrect reports were removed from the system so as not to be available to any staff. New reports were created in the clinical EMR used by Eagleville Hospital that specify pregnancy status and level of care. Eagleville Hospital staff will review all reports for accurate clinical data representation.
|
711.55(b) LICENSURE Data Collection & Record Keeping
711.55. Uniform Data Collection System.
(b) A drug and alcohol data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance.
|
Observations
During the August 22- 25, 2016 inspection, the facility failed to provide a recordkeeping system that allows for the efficient retrieval of data.
Patient lists provided by the facility did not indicate accurate information regarding pregnancy, or levels of care.
The facility's electronic medical record system was utilized to review patient records. Licensing specialists and facility staff were initially locked out of system on August 23 & 24, and were delayed in their review of the client records. Once access was achieved, two to four facility staff assisted licensing specialists in navigating the system, but the system still did not allow for the efficient retrieval of client record documentation.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Director of IT has reviewed the process and made the following corrective action to be in effect by 9-30-16.
These outdated and incorrect reports were removed from the system so as not to be available to any staff. New reports were created in the clinical EMR used by Eagleville Hospital that specify pregnancy status and level of care. Eagleville Hospital staff will review all reports for accurate clinical data representation. In the future Eagleville staff responsible for assisting the licensing specialists will verify system access with the temporary system credentials to be utilized by these licensing specials, before the scheduled licensing review date. Any issues with the temporary system credentials will be corrected by the Eagleville Hospital IT department before the start of the licensure survey. |