INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2011 through July 29, 2011 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 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 on the review of employee personnel and training records, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
Personnel records were reviewed on July 26, 2011. Employee # 7 was promoted to the position of clinical supervisor on April 7, 2011. No supervisory notes were documented employee #7's personnel or training file.
On two separate occasions, human resources staff and the director of quality assurance were asked to provide documentation of employee #7's supervisory notes. Neither were able to furnish documentation of the requested supervisory notes.
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Plan of Correction
1. One employee (#7) did not receive clinical supervision as required. Employee #7 will receive clinical supervision from the Director of Counseling and Community Integration Services on a monthly basis starting on August 29, 2011 and continuing through until January 2012. This monthly supervision will be documented and the documentation will be retained in the Human Resources department.
2. The Director of Counseling and Community Integration Services will revise policy #4000.106, Clinical Supervision, to ensure it includes the requirement for all new clinical supervisors to receive six months of clinical supervision upon hire or promotion.
3. A Departmental Compliance Objective (DCO) will be developed for the Human Resources Department to monitor the completion of clinical supervision. This will be monitored on a monthly basis.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the employee personnel record, supervision notes, and an interview with the director of quality assurance, the facility failed to document the required period of supervision for three counselor assistants.
The findings include:
Thirty-one personnel records were reviewed on July 26, 2011. Three of the thirty-one personnel records reviewed were for the position of counselor assistant, specifically records #29, 30, and 31. The required documentation of supervisory notes were not included in any of the counselor assistants' personnel or training files.
Employee #29 has a high school diploma and was promoted to the position of counselor assistant on July 15, 2010. The employee was required to have direct observation until October 15, 2010 and then close supervision until July 15, 2011. Employee #29's record only contained documentation of close supervision from February 17, 2011 to June 2, 2011.
Employee # 30 has a high school diploma and was promoted to the position of counselor assistant on September 2, 2010. The employee was required to have direct observation until December 2, 2010 and then close supervision until September 2, 2011. Employee #30's record only contained documentation of close supervision from February 7, 2011 to May 31, 2011.
Employee # 31 has an Associates degree and was promoted to the position of counselor assistant on September 23, 2010. The employee was required to have close supervision until June 23, 2011. Employee #31's record did not contain any documentation of close supervision.
The director of quality assurance was asked to furnish documentation of the required supervision notes for employees # 29, 30, and 31. The inspectors were advised that no additional documentation was available for review.
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Plan of Correction
1. Two employees (#29, 30) did not have documentation of direct observation for July 2010 through January 2011. A new clinical supervisor was hired in February 2011 and has been providing close supervision to employee's # 29 and 30 since February. Employee's # 29 and 30 will receive direct observation from their clinical supervisor from August 29, 2011 through November 29, 2011. Employee's # 29 and 30 will receive close supervision from November 29, 2011 through August 29, 2012. One employee (#31) did not receive close supervision as required. Documented close supervision will be provided to employee #31 starting from August 29, 2011 through May 29, 2012. All documentation for direct observation and close supervision will be retained by the Human Resources department.
2. A Departmental Compliance Objective (DCO) will be developed for the Human Resources Department to monitor the completion of direct observation and close supervision. This will be monitored on a monthly basis starting on August 29, 2011.
3. The Director of Counseling and Community Integration Services will revise policy #4000.106, Clinical Supervision, to ensure it includes all counselor assistant supervision requirements. Once policy #4000.106 is revised, a copy will be distributed to all counselor assistants and clinical supervisors for review. All counselor assistants and clinical supervisors will sign an acknowledgment stating that they have received and reviewed policy #4000.106.
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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
Based on a review of the Staffing Requirements Facility Summary Report, personnel records and interviews with the director of quality assurance and the staff training director, the facility failed to provide documentation of individual training plans for the July 1, 2011 through June 30, 2012 training year in twenty-two out of thirty-one personnel records.
The findings include:
Personnel records were reviewed on July 26, 2011. Annual individual training plans were required in thirty-one personnel records. Per the Staffing Requirements Facility Summary Report, the facility's training year runs from July 1, 2011 through June 30, 2012. The facility did not document individual training plans for the July 1, 2011 through June 30, 2012 training year in twenty-two personnel records.
Furthermore, the facility's Staff Training and Development Policy does not specify when annual individual training plans will be completed for staff.
An interview was held with the director of quality assurance on July 26, 201. She advised that the facility had recently created a new policy, which requires individual training plans to be documented in November 2012 for the July 1, 2011 through June 30, 2012 training year. She was then asked to provide documentation of this new policy, which she later advised was not available.
An interview was held with Human Resources staff on July 26, 2011. The staff member was asked to provide documention of the staff training policy that references when individual training plans are to be documented. She confirmed they did not have a policy for individual training plans.
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Plan of Correction
1. Current practice has been for individual training plans to be conducted with the annual performance evaluation. Evaluations were postponed in fiscal year 2011 to roll out a new evaluation process as a performance improvement initiative. With this change in process, individual training plans were delayed. Individual training plans for fiscal year 2012 will be developed for all counseling staff by September 29, 2011.
2. A Departmental Compliance Objective (DCO) will be developed for the Human Resources Department to monitor the completion of individual training plans. This will be monitored on a monthly basis starting on September 30, 2011. The Chief Compliance Officer will conduct monthly audits of counseling staff training records starting on October 3, 2011 to ensure training records contain individual training plans .
3. The Human Resources Director will develop a policy for individual training plans by August 29, 2011. This policy will include the requirements and timeframes for completion of individual raining plans for employees. Once a policy is developed, a copy will be distributed to all supervisors at Eagleville for review.
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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
Based on a review of personnel records and the Staffing Requirements Facility Summary Report and an interview with the Staff Training Director, the facility failed to ensure that each counselor completed at least 25 clock hours of training per year in two of nine counselors' records reviewed.
The findings include.
On July 26, 2011 nine counselors' personnel records were reviewed to ensure that each had completed the required 25 clock hours of training per year. According to the Staffing Requirements Facility Summary Report, the facility training year runs from July 1, 2010 to June 30, 2011. The facility failed to ensure employees #25 and #27 had 25 training hours for the 2010-2011 training year.
Employee # 25 was hired as a counselor on February 3, 2005. Employee # 25 had only 14.5 documented clock hours of training during July 1, 2010 through June 30, 2011.
Employee # 27 was hired as a counselor assistant on January 15, 2009 and promoted to a counselor on June 10, 2011. Employee # 27 had only 13 documented clock hours of training during July 1, 2010 through June 30, 2011.
On July 26, 2011, the Staff Training Director was asked to provide verification of any additional training hours. It was confirmed that there were no further training hours documented for employees #25 or #27.
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Plan of Correction
1. Two employees' (#25, 27) did not receive the required number of training hours for fiscal year 2011 and will be counseled by the Director of Counseling and Community Integration Services. This counseling will be documented in both employees' personnel records.
2. Both employees will complete the required number of training hours for training year 2011-2012 and each year thereafter.
3. The Education Coordinator will review and revise, as necessary, policy #8200.608, Staff Training and Development, to ensure the policy includes all training requirements for counseling staffs. The Human Resources department will distribute a copy of policy #8200.608 to all counselors, counselor assistants and clinical supervisors. All counselors, counselor assistants and clinical supervisors will sign an acknowledgment stating that they have received and reviewed policy #8200.608. Policy revision and review will be completed by August 29, 2011.
4. The education coordinator will distribute a report to each department head 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.
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report and an interview with the Staff Training Director, the facility failed to ensure that each counselor assistant completed at least 40 clock hours of training per year in one of one counselor assistant record reviewed.
The findings include.
On July 26, 2011 three counselor assistants' personnel records were reviewed to ensure that each had completed the required 40 clock hours of training per year. Two of those counselor assistants were new hires and were not required to have 40 hours of training. According to the Staffing Requirements Facility Summary Report, the facility training year runs from July 1, 2010 to June 30, 2011. The facility failed to ensure employee # 29 had 40 training hours for the 2010-2011 training year.
Employee # 29 was promoted to a counselor assistant on July 15, 2010. Employee # 29 had only 8.5 documented clock hours of training during July 1, 2010 through June 30, 2011
On July 26, 2011 the Staff Training Director was asked to provide verification of additional hours. It was confirmed that there were no further training hours documented for employee #29.
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Plan of Correction
1. One employee (#29) did not receive the required number of training hours for fiscal year 2011 and will be counseled by the Director of Counseling and Community Integration Services. This counseling will be documented in the employee's personnel record.
2. Employee #29 will complete 40 training hours for training year 2011-2012 and will complete 30 training hours each year thereafter.
3. The Education Coordinator will review and revise, as necessary, policy #8200.608, Staff Training and Development, to ensure the policy includes all training requirements for counseling staffs. The Human Resources department will distribute a copy of policy #8200.608 to all counselors, counselor assistants and clinical supervisors. All counselors, counselor assistants and clinical supervisors will sign an acknowledgment stating that they have received and reviewed policy #8200.608. Policy revision and review will be completed by August 29, 2011.
4. The Education Coordinator will distribute a report to each department head 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.
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704.12(a)(1)(i) LICENSURE Client/couns ratios
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.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of Staffing Requirements Facility Summary Report, and interviews with the project director and director of quality assurance, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every seven clients.
The findings include:
The current client census information and clinical staff hours were reviewed on July 27, 2011. Per regulation, inpatient nonhospital detoxification (residential detoxification) projects serving adult clients shall have one FTE counselor for every seven clients.
On July 20, 2011, from 7 am to 9 am, there were two staff on duty and a census of 17 clients, based on this information, the client to staff ration is 9:1; this ratio status exceeded the required 7:1 ratio.
On July 21, 2011 from 12 am to 7 am there were two staff on duty and a census of 18 clients, based on this information, the client to staff ration is 9:1, this ratio status exceeded the required 7:1 ratio.
On July 22, 2011 from 12 am to 7 am there were two staff on duty and a census of 17 clients, based on this information, the client to staff ration is 9:1, this ratio status exceeded the required 7:1 ratio.
The project director and director of quality assurance were interviewed on July 29, 2011. They confirmed the ratios recorded on the Staffing Requirements Facility Summary Report.
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Plan of Correction
1. On July 20, 2011 for the two-hour period of 7am to 9am there were two registered nurses and two nursing assistants on duty on the inpatient nonhospital detoxification unit. On July 21 and 22, 2011 from 12am to 7am there were two registered nurses and one nursing assistant on the inpatient nonhospital detoxification unit. Additionally a nursing supervisor and physician were on duty on hospital grounds. Both the nursing supervisor and physician were available to respond to any questions or concerns on the inpatient nonhospital detoxification unit. During previous licensure renewal inspections the nursing assistants were included in the client to staff ratio. Eagleville Hospital was informed during this licensure renewal inspection that nursing assistants are not to be included in the client to staff ratio. In light of this information provided to Eagleville, Eagleville will assign an additional staff member to the inpatient nonhospital detoxification unit for the hours of 12am to 9am starting on September 6, 2011. The addition of one staff will ensure Eagleville meets the client to staff ratio of 7:1.
2. The Chief Compliance Officer will monitor client to staff ratios for the inpatient nonhospital detoxification unit for the hours of 12am-9am on a weekly basis as of September 6, 2011 for a period of two months to ensure client to staff ratio requirement of 7:1 is met.
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705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on a physical plant inspection, the facility failed to to have the food area clean following each prepared meal.
The findings include:
The dining area of the facility was inspected on July 29, 2011, at approximately 09:30 am. The residential facility prepares onsite meals and serves the food in the main dining area. The approximate breakfast meal time is 7:00 am to 9:00 am, lunch time from 11:15 am to 1:00 pm and dinner from 4:30 pm to 6:00 pm. During the inspection, it was observed that the stainless steel container used to maintain the salads was full of ice and fresh food. Directly next to the container was a bucket of dirty water. This arrangement brought into question the sanitary status of the salad container and overall, the food preparation.
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Plan of Correction
1. The Nutrition Services Director will review and revise policy #8400.654, Sanitation, to include the specific requirement that all cleaning materials and cleaning waste be immediately disposed of or stored in the proper manner. Language will also be added to policy restricting staff from placing cleaning materials or waste in any location near food preparation. Nutrition Services staff will be educated on the revised policy and this education will be documented. The policy revision and education will be completed by August 29, 2011.
2. The Infection Control Officer will conduct monthly monitoring of the dining hall to ensure nutrition services staff are following policy #8400.654. Monitoring results will be forwarded to the Nutrition Services director for follow-up when necessary. Results will be reviewed quarterly by the Infection Control Committee.
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705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on an inspection of the central food preparation area, the facility failed to cover the utensils and store in an enclosed or covered area.
The findings include:
The dining area attached to the food preparation area was inspected on July 29, 2011 at approximately 9:30 am The facility failed to have the utensils covered or stored in an enclosed area when meals were not being served. A conversation with the food manager confirmed the breakfast meal was finished and the lunch meal was not being served for several hours. The food manager confirmed the utensils were never covered and failed to know a policy was in place to address the covering of utensils while meals were not being served.
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Plan of Correction
1. The Nutrition Services Director will review and revise policy #8400.654, Sanitation, to include the requirement to have all utensils covered or stored in an enclosed area when meals are not being served. Nutrition Services staff will be educated on the revised policy and this education will be documented. The policy revision and education will be completed by August 29, 2011.
2. As of August 29, 2011, all utensils will be covered when meals are not being served.
3. The Infection Control Officer will conduct monthly monitoring of the dining hall to ensure that all utensils are covered when meals are not being served. Monitoring results will be forwarded to the Nutrition Services Director for follow-up when necessary. Results will be reviewed quarterly by the Infection Control Committee.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document monthly fire drills.
The findings include:
The fire drill record log was reviewed on July 26, 2011. The log was reviewed from July 2010 through July 2011. The facility failed to have documentation that a fire drill was conducted monthly. The facility has several different buildings that conduct fire drills. Fire drill logs were documented for Arnstein, D' Arclay, Gersly, and Louchin buildings. Unannounced monthly fire drills were not documented during the twelve month inspection period:
Arnstein: October 2010, September 2010, August 2010, and July 2010
D'Arclay: May 2011, October 2010
Gerstly: February 2011, April 2011
Louchin: April 2011, February 2011
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Plan of Correction
1. Eagleville's policy for monthly fire drills was not followed. This was identified by the facility through Quality Management indicators in July 2010 and corrective actions have been taken including: disciplinary action and re-education for staff responsible to conducting fire drills; additional monitoring of fire drill completion by the Engineering department and monthly monitoring by the Quality Management Committee. As of June 2011 fire drills are being conducted in every building on a monthly basis.
2. All staff responsible for conducting fire drills will be counseled on the requirements of conducting the fire drill for the designated building and shift during the month that it is scheduled. Counseling will be completed by August 29, 2011.
3. Fire drill scheduling will be added to our electronic preventative maintenance system to ensure monthly completion.
4. The Engineering Supervisor will monitor fire drill completion on a weekly basis for a period of four months to ensure all fire drills are being conducted as scheduled. Weekly monitoring will begin on August 29, 2011. The Engineering Supervisor will take corrective actions as necessary.
5. The Quality Management Committee will continue to monitor fire drill completion on a monthly basis for a period of six months to ensure all fire drills are being conducted as scheduled.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the fire drill logs, the facility failed to document alternate exit routes to be used during fire drills.
The findings include:
Four facility fire drill logs were reviewed on July 26, 2011. The facility failed to document monthly alternate exits to be used during fire drills. The following buildings failed to document alternate routes during fire drills:
Arnstein: April 13, 2011
Gerstly : July 15, 2011, March 18, 2011 January 14, 2011, August 13, 2010
Louchhin: June 30, 2011, May 2011, March 25, 2011, January 18, 2011, December 25, 2010, July 19, 2010
D'Arclay: November 23, 2010, November 9, 2010
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Plan of Correction
1. All staff responsible for conducting fire drills will be counseled on the requirements of documenting on the fire drill log the use of an alternate exit route during the fire drill. Counseling will be completed by August 29, 2011.
2. The Engineering Supervisor will monitor completed fire drill logs on a weekly basis for a period of four months to ensure the alternate exit route is documented as required. Weekly monitoring will begin on August 29, 2011. The Engineering Supervisor will take corrective actions as necessary.
3. The Quality Management Committee will monitor the completed fire drill logs on a monthly basis for a period of six months to ensure the alternate exit route is documented as required.
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