INITIAL COMMENTS
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This report is a result of an on-site licensing renewal inspection and an in-site inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine in the treatment of narcotic addiction. This inspection was conducted on June 15, 2015 and July 13-15, 2015 by staff from the Division of Drug and Alcohol 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 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
Two personnel records were reviewed on June 15, 2015, to ensure clinical supervisors met the qualifications for the position of clinical supervisor. The facility failed to ensure employee # 9, a clinical supervisor had completed the core curriculum.
Employee # 9 was hired as a clinical supervisor on October 30, 2014. Employee # 9 meets the educational requirement and has 6 years clinical experience; however, based on a resume review employee # 9 did not have previous clinical supervisory experience.
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Plan of Correction
Staff member #9 will enroll in and complete core curriculum in clinical supervision by December 31, 2015
The Director of Counseling and the Staff Development Manager/Clinical Supervisor are responsible for hiring, orienting, and assuring completion of required trainings for all new clinical supervisors. Given this staff member?s status as a licensed clinical psychologist and graduate level education in clinical supervision the completion of a core curriculum in clinical supervision was not scheduled. The Director of Counseling and the Staff Development Manager/Clinical Supervisor have reviewed 704.6(c) and are now fully aware that this requirement includes any clinical supervisor that has not functioned for 2 years as a supervisor in the provision of clinical services.
Steps to assure that this deficiency does not recur:
The job descriptions for all positions that include responsibility for clinical supervision will be revised. These include Director of Counseling, Staff Development Manager/Clinical Supervisor, Program Manager, Program Director Acute Unit, Clinical Coordinator, and Senior Therapist. The following statement will be added to the Staff Development Requirements section, ?Individuals who have not functioned for 2 years as a supervisor in the provision of clinical services shall complete a core curriculum in clinical supervision. The initial competency evaluations for these positions, completed within 90 days of employment will be revised to include documentation of completion or scheduling of core curriculum training if required.
The Director of Counseling and the Staff Development Manager are responsible for reviewing job descriptions with any new clinical supervisors as part of the orientation process. They are also responsible for completion of the initial competency. The Director of Human Resources is responsible for assuring that the relevant job descriptions and initial competencies are revised.
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant documented to the facility director that they were working toward counselor status and met the requirements for counselor within 5 years of employment.
The findings include:
One counselor assistant's personnel record was reviewed on June 15, 2015. The facility failed to ensure employee # 13 was working toward counselor status upon completion of the calendar year.
Employee # 13, a high school level counselor assistant was hired February 2, 2009. The facility failed to ensure employee # 13 was working toward counselor status upon completion of the calendar year. In addition, employee # 13 failed to meet the requirements for counselor within 5 years.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member #13 was hired as a Nursing Assistant on 2-2-09 and promoted to the position of Counselor Assistant on 10-14-10. He will either complete requirements for counselor assistant, be successful in obtaining an exemption from DDAP, or be demoted from this position on 10-13-15.
Steps to ensure that the deficiency does not recur:
The job description for Counselor Assistant will be revised to include a statement that the Counselor Assistant shall meet the requirements for counselor within 5 years of employment. The job description currently specifies that the Counselor Assistant document that he is working toward Counselor status each calendar year. The Clinical Coordinator or Program Manager orienting the new Counselor Assistant will review the job description with the employee during the orientation process.
An annual performance evaluation and competency assessment is conducted on each employee at the completion of the calendar year of employment. The competency assessment for Counselor Assistant will be revised to include receipt of documentation that the Counselor Assistant is working toward Counselor status. The competency assessment will also be revised to include a notice to the Counselor Assistant that failure to complete the requirements for Counselor by the end of the 5th year will result in demotion or termination of employment.
The Director of Human Resources is responsible for ensuring completion of the revisions of job description and competency assessments.
Clinical Coordinators and Program Managers are responsible for reviewing job descriptions with each new employee during the orientation process and completing competency assessments annually.
Clinical Coordinators and Program Managers are responsible for receiving annual documentation of the Counselor Assistant working toward counselor status, documenting receipt on the competency assessment and forwarding documentation to the Human Resources department for inclusion in the Counselor Assistant?s file. During the 4th competency assessment the Counselor Assistant will be required to submit a plan for completion of requirements for Counselor by the end of the 5th year. The Clinical Coordinator or Program Manager will notify the Counselor Assistant in writing that failure to complete requirements or secure an exception from the Department will result in demotion or termination of employment. Both of these documents will be submitted to the Director of Counseling and the Director of Human Resources.
The Director of Counseling is responsible for ensuring that the Clinical Coordinators and Program Managers complete and submit the required documentation, competency assessments, and plan for completion of requirements. Demotion/termination will be pursued if requirements are not met.
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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
Based on a review of personnel records and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that all staff persons receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training.
The findings include:
Two personnel records requiring documentation of a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training were reviewed on June 15, 2015. The facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training; specifically employees, # 12 and 14.
Employee # 12, a counselor was hired April 14, 2014. HIV/AIDS training was to be completed within the first year of employment or by April 14, 2015. The facility failed to ensure employee # 12 completed HIV/AIDS training at the time of inspection on June 15, 2015. In addition, the facility documented on the Staffing Requirements Facility Summary Report form that employee # 12 did not complete the training.
Employee # 14, a counselor was hired May 15, 2014. TB/STD training was to be completed within the first year of employment or by May 15, 2015. The facility failed to ensure employee # 14 completed TB/STD training at the time of inspection on June 15, 2015. In addition, the facility documented on the Staffing Requirements Facility Summary Report form that employee # 14 did not complete the training.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff member #12 is scheduled to attend the DDAP HIV/AIDS training on
9-25-15.
Staff member #14 is scheduled to attend the DDAP TB/STD training on
10-2-15.
Steps to assure that the deficiency does not recur.
The Staff Development Manager/Clinical Supervisor will generate quarterly reports identifying each staff member?s progress in completing all department required trainings. These reports will be sent to Clinical Coordinators, the Director of Counseling, the Director of Nursing, the Director of Human Resources and other relevant Department Heads for review. The Staff Development Manager/Clinical Supervisor will assist staff members in locating and scheduling required trainings to assure completion within the required time frames. Staff members that do not demonstrate progress toward completion of required trainings will receive coaching to reinforce the need for completion of training. Staff members that do not complete required trainings will be suspended pending completion of required trainings.
The Staff Development Manager/Clinical Supervisor is responsible for generating quarterly reports and assisting staff members in scheduling trainings. The Clinical Coordinators and Department Heads are responsible for monitoring each staff member?s progress toward completion of training. The Director of Human Resources is responsible for assuring that documented coaching is provided and that individuals that have not completed required training are suspended pending completion of training.
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704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.
The findings include:
Three employee records were reviewed on June 15, 2015, for documentation of counselor training hours. The facility failed to ensure that employee # 11, a counselor who was hired August 21, 2007, completed at least 25 clock hours of annual training for the facility's training year, July 1, 2013 through June 30, 2014. Employee # 11's training file only included documentation of 19.5 training hours.
In addition, the facility documented on the Staffing Requirements Facility Summary Report form which was completed by the facility on June 15, 2015, that employee # 11 received 19.5 hours of training.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There appears to be a discrepancy between the personnel records and the records in our training system which indicated that staff member #11 had 33.3 training hours rather than 19.5 hours. The Human Resources Department will assure accurate record keeping of training hours in all staff members personnel records. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent in one of seven inpatient hospital detox patient records reviewed.
The findings include:
Seven inpatient hospital detox patient records were reviewed on July 14-15, 2015. The facility failed to document an informed and voluntary consent in one patient record, #24.
Patient #24 - A fax was sent out on January 9, 2015 to an agency, but an informed and voluntary consent was not documented in patient #24's record. The facility failed to obtain an informed and voluntary consent for an agency prior to releasing information pertaining to the patient's treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were counseled and a training on Release of Information was conducted by our Chief Compliance and Privacy Officer on 7-21-15 at the Counseling Department Staff meeting. Training included the requirement of securing a Release of Information before any information is released and that all information released must meet Chapter 255.5 regulations. Chart audits will be conducted to assure compliance.Each Clinical Coordinator and Program Manager complete a review of 10 medical records for each unit under their supervision each month. The chart audits include reviewing consents to release information for their presence, accuracy, and correct completion. The results of these audits are recorded on Excel spreadsheets and submitted to the Director of Counseling and the Director of Quality Management. The Director of Counseling presents a quarterly summary report to the Quality Management Committee, which includes representatives of the Hospital Board of Directors.
Clinical Coordinators and Program Managers are responsible for counseling staff when problems are identified. The Director of Counseling is responsible for assuring that any issues identified in the chart audit process are addressed through supervision of the Clinical Coordinators and Program Managers. The Quality Management Committee is responsible for assuring that any deficiencies identified through regulatory review processes are corrected and will monitor this specific item each quarter.
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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.
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Observations
Based on review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of methadone, a narcotic agent in two of five hospital detox methadone patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Five hospital detox methadone patient records were reviewed on July 14-15, 2015. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to complete a drug screen urinalysis prior to the administration of Methadone, a narcotic agent in client records, #25 and 26.
Record #25 - Patient was admitted on March 15, 2015. The urine screen results were documented on March 16, 2015 at 14:13 pm. The initial dose of Methadone was given on March 16, 2015 at 12:11 pm.
Record #26 - Patient was admitted on March 14, 2015. The urine screen results were documented on March 15, 2015 at 5:26 am. The initial dose of Methadone was given on March 14, 2015 at 18:17 pm.
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Plan of Correction
Results of drug screen uninalysis are transmitted from the laboratory to the EMR. Interface issues at one point prevented the results from appearing on the EMR. Staff were able to verify results by going online to the ADL website. Before dosing, if lab results are not listed in the EMR, staff will document steps taken to confirm urine drug screen results. Patients will not receive Methadone until lab results are confirmed.Director of Information Technology will address any further interface issues with Atlantic Diagnostic Laboratory. Nurses will be instructed to document any interface issues in EMR and communicate to the IT department by Director of Nursing via EMail before 9-15-15.Director of Nursing will EMail Protocol for lab result confirmation before dosing to medical and nursing staff by 9-15-15. Compliance will be monitored via monthly chart reviews by Nursing QM. |