INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from July 29, 2013 to August 1, 2013, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based upon the review of employee records, the facility failed to provide documentation that one of one clinical supervisors participated in monthly meetings with their supervisor for the first 6 months of employment in that position.
The findings include:
As per documentation presented during the inspection, the facility hired one new clinical supervisor since the 2012 annual licensing inspection.
Employee records were reviewed from July 29-31, 2012. The facility failed to provide documentation that employee # 10 had participated in monthly meeting with their supervisor during their first 6 months of employment as a clinical supervisor.
Employee # 10 was hired as a clinical supervisor on October 18, 2012, and was required to participate in monthly meetings with their supervisor up to April 18, 2013. The record did not include documentation of any monthly meetings as of the date of inspection.
The Patient Safety Officer confirmed the findings prior to the exit interview.
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Plan of Correction
The Director of Clinical Counseling will assume responsibility for the provision of clinical supervision immediately for employee # 10.
Employee #10 will have six months of supervision included in the file.
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based upon the results of the physical plant inspection, the facility failed to ensure that three of forty-two mattresses on the second floor of the Levy Building remained in good repair and were fire retardant.
The findings include:
The physical plant inspection for the second floor of the Levy Building was conducted on July 31, 2013. Mattresses on the beds included tags that disclosed that the inner material of the mattresses was flammable. The facility failed to ensure that mattresses contained in rooms # 207, 231 and 232 remained in good repair and were fire retardant.
The bed located next to the outer wall in room # 207 contained a mattress that had tears and/or cracks on the surface that exposed the flammable inner material.
The bed located next to the outer wall in room # 231 contained a mattress that had tears and/or cracks on the surface that exposed the flammable inner material.
The bed located next to the outer wall in room # 232 contained a mattress that had tears and/or cracks on the surface that exposed the flammable inner material.
The findings were confirmed by the Maintenance Supervisor during the physical plant inspection.
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Plan of Correction
The Director of Plant Operations had mattress removed and replaced all mattress with integrity issues on the day of the Survey.
A full review and inspection of every mattress was conducted by Environmental Services and a monthly inspection of mattresses will be added to the facility checklist and environmental rounds. The findings of these inspections will be reported to the Infection Preventionist and reported to QM for a period of 4 months.
An electronic message was sent to all front line caregivers to remind them of the guidelines for mattress integrity and procedures for replacement.
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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
Based upon the results of the physical plant inspection, the facility failed to ensure that all showers on the second floor of the Levy Building had slip-resistant surfaces.
The findings include:
The physical plant inspection for the second floor of the Levy Building was conducted on July 31, 2013. The showers located within the client bedrooms listed below were in the following condition at the time of inspection:
Client bedroom # 229 - no slip resistant surface.
Client bedroom # 208 - no slip resistant surface.
Client bedroom # 206 - no slip resistant surface.
Client bedroom # 204 - no slip resistant surface.
Client bedroom # 202 - a one inch slip resistant strip was located on one of the outer edges of the shower base.
The findings were confirmed by the Maintenance Supervisor during the physical plant inspection.
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Plan of Correction
Director of Plant Operations did completed full review and inspection of every building. This is conducted by Director of Plant operations on a monthly basis and on weekly Environmental Rounds on selected units includes shower surface slip resistance.
The Monthly inspections of includes bathrooms and slip resistant surface. The surfaces noted to be defieicent were corrected. They are currently on the inspection checklist and environmental rounds and Environmental Rounds team.
A sample of showers will be inspected to ensure current slip resistance is inspected, Reported to QM for a period of 4 months.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based upon the results of the physical plant inspection, the facility failed to ventilate one of one bathrooms in Levine Dining Hall and four of five toilets and/or wash rooms on the second floor of the Gerstley Building.
The findings include:
The physical plant inspection for the Levine Dining Hall was conducted on July 29, 2013. The exhaust fan in the left side bathroom was not working at the time of inspection.
The physical plant inspection for the Gerstley Building was conducted on July 30, 2013. The exhaust fans in the following toilets and/or wash rooms located on the second floor were not working at the time of inspection:
- the bathroom located next to the laundry room
- the bathroom located inside room 204
- the bathroom located inside room # 202
- the wash room located next to room # 202
The findings were confirmed by the Maintenance Supervisor during the physical plant inspection.
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Plan of Correction
This vent was replaced July 30,2013
These fans were repaired on August 1, 2013.
The Director of Plant Operations completed review and inspection of every building. This is conducted by Director of Plant Operations and designee on a monthly basis and on weekly Environmental Rounds.
The Monthly inspections of fans are currently on the inspection checklist and now added to the environmental rounds. The findings of these inspections will be reported to the Infection Preventionist . A random spot check of function will be completed Infection Preventionist and Environmental Rounds team. Reported to QM for a period of 4 months.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based upon the results of the physical plant inspection, the facility failed to ensure that heaters that were not permanently mounted or installed were not permitted in the facility.
The findings include:
The physical plant inspection for the D'Arclay Building was conducted on July 29, 2013. A portable heater was located inside room # 242.
The findings were confirmed by the Director of Quality Management during the physical plant inspection.
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Plan of Correction
This portable heater was located inside room # 242 was removed on the day of inspection and the staff member was instructed about the permitted.
A hospital wide email was distributed to remind staff of the prohibited practice of portable heater use.
This will be monitored during environmental rounds to ensure regulation adherence. |
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
Based upon the review of client records, the facility failed to adhere to the restrictions imposed at 4 PA Code, subsection 255.5(b), regarding the specific information disclosed, in two of fourteen client records.
The findings include:
4 PA Code, subsection 255.5(b) specifies that information released to judges, probation or parole officers (criminal justice system) shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Fourteen client records were reviewed from July 29-31, 2013. The facility failed to document informed consent forms that limited the specific information disclosed in client records # 16 and 19.
Client # 16 was admitted on June 14, 2013, and was still an active client on the date of inspection. The record included a signed consent form for inmate services at a county prison that was dated June 14, 2013. The information to be disclosed exceeded the restrictions imposed at 4 Pa. Code, subsection 255.5(b) as the consent form permitted for the release of information that included client "histories."
Client # 19 was admitted on April 18, 2013, and was still an active client on the date of inspection. The record included a signed consent form for a drug court that was dated April 18, 2013. The information to be disclosed exceeded the restrictions imposed at 4 Pa. Code, subsection 255.5(b) as the consent form permitted for the release of information that included client "histories."
During the client record review, the Patient Safety Officer confirmed that the consent forms were included in the client records. During the exit interview, the Facility Director contended that the Information To Be Disclosed was permitted as the consent forms were for other treatment providers.
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Plan of Correction
In the two records identified the releases had been completed in the intake and assessment office. These patients had been referred by representatives of the criminal justice system and the admissions officer completed both a release for a referral source and a release for court mandated treatment. The Director of Counseling met with this staff member and provided education indicating that if the admission is court mandated that only the court mandated release can be utilized. The admissions officer understood this instruction and implemented immediately with the remainder of the department.
The titles of the release forms may have contributed to the admission officer's confusion about the appropriate form to use. The Director of Counseling and the Director of Quality Management will review release of information forms and revise to reduce the possibility of confusion.
In some instances when a patient is taken in to custody by the criminal justice system and removed from treatment continuity of care issues may arise. If an individual is prescribed medications as part of a detoxification protocol, physical health condition, or psychotropic medications, adverse consequences may result if these medications are not continued in the correctional facility in which they are confined. In these circumstances Inmate Services may contact the treatment provider at the request of the facility's medical staff to request information including diagnoses and medications. In these instances the release will be confined to these specific items and will clearly specify that the information is to be provided to the medical staff at the correctional facility. These requests are processed by the Medical Records Department and the Director of Medical Records will assure that releases are appropriately constructed and confined to this information only.
In instances when Drug Court participants are in treatment the court mandated release will be utilized and only permissible information will be released to Drug Court.
The review of charting requirements for release of information will be completed by the Director of Intake and Assessment.
Director of Counseling Services and Community Integration will review these requirements at the Clinical Management Meetings. This has been added to the Clinical Coordinators medical record reviews and will be monitored for a minimum of four months.
The Director of Counseling Services and Community Integration will report the Monthly chart reviews to QM for a period on four months at a minimum. Staff requiring additional training will be reeducated as identified.
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