INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2006 to August 10, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on September 7, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Staff numbers 11, 14, 29 and 23 did not have training needs assessments/plans completed for training year 2006-2007.
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Plan of Correction
While the training needs assessment for 2006-2007 was completed, because all individual training plans were not completed, the assessment was not able to contain a complete assessment for use during the year. The cited 2006-2007 individual training plans will be completed by all applicable program directors/supervisors by September 30, 2006, after which the annual needs assessment will be re-evaluated for any necessary changes by the staff development manager. |
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
Staff numbers 11, 14, 29, and 23 did not have individual training plans completed for training year 2006-2007.
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Plan of Correction
Not all individual training plans were completed for training year 2006-2007. All outstanding individual training plans will be completed by all applicable program directors/supervisors by September 30, 2006. The Human Resources Department will complete an inventory of all individual training plans to ensure that all plans have been completed and submitted. |
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.
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Observations
Staff numbers 1 and 2 did not document HIV/AIDS training.
Staff numbers 11, 19, and 25 did not document TB/STD training.
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Plan of Correction
Staff member 1 did complete the HIV/AIDS training; however, certificates of attendance were not filed in the training file. The training report for this staff member can be submitted upon request. Staff member 2 has not attended the HIV/AIDS training but has until 11/21/06 (hired 11/21/05) to attend the training or provide documentation of previous attendance. Staff members 11 and 25 did complete the TB/STD training; however, certificates of attendance were not filed in the training files. The training report for these staff members can be submitted upon request. Staff member 19 did not attend the TB/STD training. Staff member 19 will attend the scheduled TB/STD training to be held on 11/2/06. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Staff number 23 had 9 hours of training. This is 3 hours short of the required 12 hours.
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Plan of Correction
Staff member 23 had only 9 hours of the 12 required. Staff member 23 will complete 12 hours of training for training year 2006-2007 and each year thereafter. The staff development manager will distribute a report to each supervisor quarterly detailing the training hours achieved by each staff member thus far in the training year. The staff member's supervisor will monitor the list for each staff member and ensure that adequate progress is being made in achieving the required training hours. If adequate progress is not being made, the supervisor will follow up with the staff member to ensure all training hours are completed for the year. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Although training was documented, staff numbers 4, 10, 16, 20, 21, and 25 did not obtain the required 25 hours of training.
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Plan of Correction
Staff members 4, 10, 16, 20, 21, and 25 did not obtain the required 25 hours of training. Staff members 4, 10, 16, 20, 21, and 25 will complete 25 hours of training for training year 2006-2007 and each year thereafter. The staff development manager will distribute a report to each supervisor quarterly detailing the training hours achieved by each staff member thus far in the training year. The staff member's supervisor will monitor the list for each staff member and ensure that adequate progress is being made in achieving the required training hours. If adequate progress is not being made, the supervisor will follow up with the staff member to ensure all training hours are completed for the year. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
On the first floor in the D' Arclay building there is a group counseling office with a door window, a second group counseling office with a door window as well as a window that opens out to the smoking deck, and a third group counseling office that has glass walls. Individuals in the hallways and the smoking deck can view the activities in these rooms through these windows.
The facility needs to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
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Plan of Correction
The physical plant of the dual diagnosis units was designed with visual access of group meeting rooms to ensure the safety of the therapist. Except for the glass enclosed room and the room with the glass sliding door, these windows are small and a person must directly look through the windows to see in. The room with the smoking deck is the one with the glass sliding door; there is no other access to the smoking deck other than the glass sliding door. Clients/others would not have access to the smoking deck during a group therapy session. However, to ensure the visual privacy of the group, window coverings will be purchased for the glass windows/doors for use during therapy sessions. The director of purchasing will order all necessary window coverings, and the director of environmental services will follow up on this issue to ensure the window coverings are installed. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Several lavatories in the D'Arclay and Levy buildings had showers that did not have slip resistant surfaces.
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Plan of Correction
All bathrooms in the Levy and D'Arclay buildings will be surveyed to ensure that all showers have slip resistant surfaces. Those found not to be slip resistant will be made slip resistant. The director of environmental services will follow up on this issue to ensure it is completed.
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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
Temperature records indicate that refrigerators number 1 and number 7 exceeded the agency's maximum temperature for refrigerators (38 degrees) on numerous occasions.
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Plan of Correction
Policy 8400.651, Food Storage, Preparation and Service, was revised as of 8/22/06 to read "Perishable foods are stored in appropriate refrigeration (40°F or below)". This temperature meets the requirement of this standard. The Refrigerator Temperature Log was revised as of 8/22/06 to include a section for corrective actions/comments. Staff have been notified that if a refrigerator temperature is above 40°F that a corrective action must be documented, as well as the result from this corrective action. The director of nutrition services will monitor the Refrigerator Temperature Logs once per month for six months to ensure that the Logs document corrective actions and results of corrective actions for any temperatures on the Log above 40°F. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The training files for staff numbers 4, 7, 8, 11, 13, 14, 17, 18, 23, 24 , 25, and 32 did not document fire extinguisher training.
Instruction may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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Plan of Correction
Fire extinguisher training is provided to all new staff during staff orientation training held the first day of employment. Staff who do not have the training are staff that completed new staff orientation prior to the fire extinguisher training being offered during it. All staff who did not complete the training will be trained. The staff development manager will coordinate with the safety coordinator to ensure that all necessary staff receive the training. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Fire drills were missing for the following buildings for the designated months:
Gerstley - 7/06, 5/06, 2/06, and 11/05.
Levine - 7/06
Louchheim - 7/06, 5/06, 1/06, and 11/05.
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Plan of Correction
Fire drills are pre-scheduled but may be rescheduled due to a number of factors. Rescheduled fire drills have recently been found to have occurred in the next month after which they were scheduled. Fire drills, including rescheduled drills, will be held in the month in which they are scheduled. Monitoring to ensure that fire drills are being conducted as scheduled, or if rescheduled then conducted in the correct month, will be completed monthly by the director of environmental services and safety coordinator. |
157.23 (b) LICENSURE Patient records.
157.22 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).
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Observations
Two general consents to release information were found in client records reviewed during the inspection.
The form titled "Informed Consent, General Consent, as constructed, permits releases to: "facilitate outside consultations and/or treatment as necessary...". It also permits "..the exchange of medical or psychiatric information..". This language is general in nature and does not permit the client to give an informed consent regarding the specific types of information to be released in accordance with this regulation.
The Financial Arrangement Payment Agreement consent Authorizes Eagleville Hospital to disclose to private and/or government third party payers only the information from the medical record which is reasonably necessary to effectuate the purpose which is payment of the cost of my care. This language is also considered a general consent and does not permit the client to give an informed consent regarding the specific types of information to be released in accordance with this regulation.
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Plan of Correction
Two general consents to release information were found in the client record during the inspection. The director of medical records will revise both consents to make the language in the consents specific and informed regarding any information that is to be released. |
711.62(a)(4) LICENSURE Records of Services Provided
711.62. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(4) Record of services provided.
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Observations
Records of service did not consistently identify the provider of service. The clinical staff signing off on the progress notes was frequently not identified as the provider of service on the service records in files reviewed.
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Plan of Correction
The record of service did not consistently identify the provider of service. The record of service is an electronic document generated through the electronic client record. The inconsistent identification of the provider of service is due to how the electronic record of service is produced. The electronic record of service will be revised to ensure that the provider of service consistently appears. Any staff training on new procedures resulting from this change in the electronic record of service will be provided to all applicable staff. Monitoring to ensure that the record of service consistently contains the provider of service will be completed monthly by the program directors/supervisors through the completion of client record reviews. |
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:
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Observations
Two general consents to release information were found in files reviewed .
The form titled "Informed Consent, General Consent", as constructed, permits releases to: "facilitate outside consultations and/or treatment as necessary...". It also permits "..the exchange of medical or psychiatric information..". This language is general in nature and does not permit the client to give an informed consent regarding the specific types of information to be released in accordance with this regulation.
The Financial Arrangement Payment Agreement consent Authorizes Eagleville Hospital to disclose to private and/or government insurance only the information from the medical record which is reasonably necessary to effectuate the purpose which is payment of the cost of my care. This language is also considered a general consent and does not permit the client to give an informed consent regarding the specific types of information to be released in accordance with this regulation
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Plan of Correction
Two general consents to release information were found in the client record during the inspection. The director of medical records will revise both consents to make the language in the consents specific and informed regarding any information that is to be released. |
711.62(c)(2)(ii) LICENSURE Specific Information Disclosed
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:
(ii) The specific information disclosed.
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Observations
Consents to release information forms found in files reviewed included language which would permit the disclosure of "..HIV/AIDS testing , history and/or results..." and "... psychiatric evaluations , treatment plans, progress notes ....discharge summary..." to funding entities and government agencies. This information exceeds parameters established by 4 Pa. Code subsection 255.5.
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Plan of Correction
Eagleville Hospital continues to educate 3rd party payors, managed care organizations and others, as appropriate, on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard. All employees will receive training in confidentiality, including the limits of disclosure. Medical records will be monitored. |
711.51(b)(3)(iii) LICENSURE Personal History
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories older than six months have been inappropriately updated (see April 1996 Licensing Alert). Personal histories in files reviewed did not consistently address all required areas in detail. Histories should be constructed to collect as much detail as possible.
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Plan of Correction
Policy #4000.011, Comprehensive Clinical Histories, allows for an interim personal history to be completed within one year of a previous admission. This policy will be changed to allow for interim personal histories to be completed within six months of completion of the previous history. In addition, personal histories were found to inconsistently contain detailed information. Staff training on revised timeframes and documentation of personal histories will be provided to all applicable staff. Monitoring to ensure that the personal histories consistently contain sufficient detail will be completed monthly by the program directors/supervisors through the completion of client record reviews. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing from record # 9. Psychosocial evaluations in records reviewed did not consistently provide detailed information identifying possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
The psychosocial evaluation missing from record 9 was completed later that day following completion of the survey. It was due on the day it was completed. Staff training on documentation of psychosocial evaluations will be provided to all applicable staff to ensure sufficient detail on information leading to the client's current situation is consistently documented. Monitoring to ensure that the psychosocial evaluations consistently contain sufficient detail will be completed monthly by the program directors/supervisors through the completion of client record reviews. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Treatment plan updates were missing in client records # 10 and 11.
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Plan of Correction
The treatment plan update in client record 10 was not actually due until 8/22/06; however, several objectives on the treatment plan were due for completion. Staff will be reminded that objectives due prior to the due date of the treatment plan update need to be addressed by their due date. Client record 11 contained three treatment plans, one for each program the client was in, but no treatment plan updates. Staff will be reminded that a treatment plan update will be completed for all clients prior to their transfer to another program. Monitoring to ensure that treatment plan updates are being completed as required will be completed monthly by the program directors/supervisors through the completion of client record reviews. |
711.53(a)(2) LICENSURE Records of Service
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(2) Record of services provided.
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Observations
Records of service did not consistently identify the provider of service. The clinical staff signing off on the progress notes were frequently not identified as the providers of service on the service records in the client records reviewed.
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Plan of Correction
The record of service did not consistently identify the provider of service. The record of service is an electronic document generated through the electronic client record. The inconsistent identification of the provider of service is due to how the electronic record of service is produced. The electronic record of service will be revised to ensure that the provider of service consistently appears. Any staff training on new procedures resulting from this change in the electronic record of service will be provided to all applicable staff. Monitoring to ensure that the record of service consistently contains the provider of service will be completed monthly by the program directors/supervisors through the completion of client record reviews.
October 31, 2006
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711.53(a)(4) LICENSURE Progress Notes
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Progress notes were missing in two client records reviewed (# 5 , 7).
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Plan of Correction
The progress notes missing from two client records were the responsibility of one staff person. This issue has already been addressed with this staff member in supervision. Monitoring of her progress note documentation will be completed by her supervisor to ensure that all progress notes are being completed as required. |
711.53(a)(7) LICENSURE Follow-up Information
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Follow up was not documented in two of two applicable client records, (#2 and # 4).
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Plan of Correction
Follow up documentation was not found in two client records. Staff training on completion of follow up will be provided to all applicable staff to ensure follow up is completed and documented as required. Monitoring to ensure that the follow up is completed will be done monthly by the program directors/supervisors through the completion of client record reviews. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
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:
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Observations
Two general consents to release information were found in files reviewed .
The form titled "Informed Consent, General Consent", as constructed, permits releases to: "facilitate outside consultations and/or treatment as necessary...". It also permits "..the exchange of medical or psychiatric information..". This language is general in nature and does not permit the client to give an informed consent regarding the specific types of information to be released in accordance with this regulation.
The Financial Arrangement Payment Agreement consent Authorizes Eagleville Hospital to disclose to private and/or government insurance only the information from the medical record which is reasonably necessary to effectuate the purpose which is payment of the cost of my care. This language is also considered a general consent and does not permit the client to give an informed consent regarding the specific types of information to be released in accordance with this regulation
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Plan of Correction
Two general consents to release information were found in the client record during the inspection. The director of medical records will revise both consents to make the language in the consents specific and informed regarding any information that is to be released. |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
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:
(ii) The specific information disclosed.
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Observations
Consents to release information in client records reviewed included language which would permit the disclosure of "..HIV/AIDS testing , history and/or results..." and "... psychiatric evaluations , treatment plans, progress notes ....discharge summary..." to funding entities and government agencies . This information exceeds parameters established by 4 Pa. Code subsection 255.5.
Consents to release information did not consistently have specific information identified on release forms.
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Plan of Correction
Eagleville Hospital continues to educate 3rd party payors, managed care organizations and others, as appropriate, on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard. All employees will receive training in confidentiality, including the limits of disclosure. Medical records will be monitored. |