INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on August 16, 2022 through August 18, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.11(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, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2021 through June 30, 2022 training year in one of five applicable personnel records reviewed.
Employee # 6 was hired as a counselor on May 4, 2020. The personnel record documented 14.75 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The VP of Counseling will send a Memo to all counselors explaining their responsibility to complete the mandatory 25 hours of training required by the regulations and informing them that the hours will be tracked on a monthly basis. This memo will be sent no later than 9/30/2022.
The Director of Clinical Education will run a report of each counseling staff's training on a monthly basis and provide the reports to the VP of Counseling and the Clinical Directors who will disseminate it to the supervisors for follow-up with their direct reports.
This report will list, by each counseling employee, their hours of training and the outstanding training modules.
Clinical Supervisors will use these monthly training reports to track the progress of their direct reports. If the supervisor determines a staff member is not progressing through their hours, this matter will be addressed in supervision.
The VP of Counseling will be responsible for this Plan of Correction and will report to the Quality Management Committee at its last meeting prior to June 30 regarding the compliance of staff with training requirements and the efforts that are being undertaken to assure complete compliance with these requirements.
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711.62(c)(2)(i) LICENSURE Name of Person/agency/organization
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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms in one of seven client records reviewed.
Client # 21 was admitted to the inpatient non-hospital detoxification activity on August 20, 2021 and was discharged on August 23, 2021. There was a blank release of information form, signed and dated by the client and witness on August 20, 2021, that did not include the name of the person, agency or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will provide a training on completion of Consents and Release of Information Forms to the Admissions Registration Staff.
This training will include the requirement that all forms must specify the name of the person, agency, or organization to whom the disclosure would be made. This training will be completed by 09/30/2022.
The Director of Admissions will perform chart audits of ten random charts per week to assure that the consents for release of information contain the name of the person, agency or organization to whom disclosure can be made. These chart audits shall be performed from 9/30/22 through 10/31/2022. The Director of Admissions will be responsible for assuring that this requirement is met and follow up occurs with any noncompliant staff and, to the extent possible, the patient if the forms do not contain the required information.
Prior to releasing any information, the Medical Records Department shall assure that the consent and/or release form was fully completed with the name of the pertinent person, agency or organization.
The Director of Admissions will be responsible for this Plan of Correction and will present the results of the audits to the Quality Management Committee meeting in November 2022.
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711.53(c)(2)(i) LICENSURE Person/Agency/Org to Whom Disclosure Made
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:
(i) The name of the person, agency, organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on consent to release information forms in one of seven client records reviewed.
Client # 26 was admitted to the inpatient non-hospital activity on July 15, 2022 and was discharged on August 3, 2022. The release of information form for the funding source and the release of information forms with purposes of the notification of admission, the notification of emergency or unplanned discharge, and the notification of seclusion or restraint were all signed and dated by the witness on July 15, 2022; however, none of the release forms included the name of the person, agency or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will provide a training on completion of Consents for Release of Information to the Admissions Registration Staff. This training will include the requirement that all forms must specify the name of the person, agency, or organization to whom the disclosure would be made. This training shall be completed by 09/30/2022.
The Director of Admissions will perform chart audits of a random ten charts per week to assure that the consents for release of information forms contain the name of the person, agency or organization to whom disclosure can be made. These chart audits shall be performed from 9/30/22 through 10/31/2022. The Director of Admissions will be responsible for assuring that this requirement is met and that follow up occurs with any noncompliant staff and, to the extent possible, the patient, if the forms do not contain the required information.
Prior to releasing any information, the Medical Records Department will assure that the consent and/or release form was fully completed with the name of the pertinent person, agency or organization.
The Director of Admissions will be responsible for this Plan of Correction
and will present the results of these audits to the Quality Management Committee meeting in November 2022.
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711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in one of seven client records reviewed.
Client # 27 was admitted to the inpatient non-hospital activity on October 12, 2021 and was discharged on October 26, 2021. The release of information form to an outside company was signed and dated by the client on October 21, 2021; however, the form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will provide a training on completion of Consents for Release of Information Forms to the Admissions registration staff.
This training will include the requirement that all forms must specify the purpose of the disclosure. This training shall be completed by 09/30/2022.
The Director of Admissions will perform chart audits of a random ten charts per week to assure that the consents for release of information forms are completed correctly and contain the purpose of disclosure. These chart audits will be performed from 9/30/22 through 10/31/2022.
The Director of Admissions will be responsible for assuring that this requirement is met and follow up occurs with any noncompliant staff and, to the extent possible, the patient if the forms do not contain the required information.
Prior to releasing any information, the Medical Records Department shall assure that the consent and/or release form was fully completed with the purpose of disclosure.
The Director of Admissions will be responsible for this Plan of Correction and will present the results of these audits to the Quality Management Committee meeting in November 2022.
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711.53(c)(2)(iv) LICENSURE Dated Signature of Client/guardian
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:
(iv) The dated signature of client or guardian.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on consent to release information forms in one of seven client records reviewed.
Client # 26 was admitted to the inpatient non-hospital activity on July 15, 2022 and was discharged on August 3, 2022. The release of information forms for the funding source and the release of information forms with purposes of the notification of admission, the notification of emergency or unplanned discharge, and the notification of seclusion or restraint were all signed and dated by the witness on July 15, 2022; however, none of the forms included the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will provide a training on completion of Consents for Release of Information Forms to the Admissions registration staff.
This training will include the requirement that all forms must contain the dated signature of the client. This training shall be completed by 09/30/2022.
The Director of Admissions will perform chart audits of a random ten charts per week to assure that the consents for release of information forms are completed correctly and contain the dated signature of the client. These chart audits shall be performed from 9/30/22 through 10/31/2022.
The Director of Admissions will be responsible for assuring that this requirement is met and that follow up occurs with any noncompliant staff and, to the extent possible, the patient, if the forms do not contain the required information.
Prior to releasing any information, the Medical Records Department shall assure that the consent and/or release form was fully completed with dated signature of the client.
The Director of Admissions is responsible for this Plan of Correction and will present the results of these audits to the Quality Management Committee meeting in November 2022.
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711.53(c)(2)(v) LICENSURE Witness dated signature
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:
(v) The dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on consent to release information forms in one of seven client records reviewed.
Client # 27 was admitted to the inpatient non-hospital activity on October 12, 2021 and was discharged on October 26, 2021. The release of information form to an outside company was signed and dated by the client on October 21, 2021, the release of information to a probation officer was signed and dated by the client on October 19, 2021 and the release of information form to a friend of the client were all signed and dated by the client on October 15, 2021. However, each form did not include the dated signature of the witness.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will provide a training on completion of Consents for Release of Information Forms to the Admissions Registration Staff.
This training will include the requirement that all forms must contain the dated signature of a witness. This training shall be completed by 09/30/2022.
The Director of Admissions will perform chart audits of a random ten charts per week to assure that the consents for release of information forms contain the dated signature of the witness. These chart audits shall be performed from 9/30/22 through 10/31/2022.
The Director of Admissions will be responsible for assuring that this requirement is met and that follow up occurs with any noncompliant staff and, to the extent possible, the patient, if the forms do not contain the required information.
Prior to releasing any information, the Medical Records Department shall assure that the consent and/or release form was fully completed with the dated signature of a witness.
The Director of Admissions will be responsible for this Plan of Correction and will present the results of these audits to the Quality Management Committee meeting in November 2022.
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711.53(c)(2)(vi) LICENSURE Consent's Expiration Date
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:
(vi) The expiration date of the consent.
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Observations
Based on a review of client records, the facility failed to document the expiration date of the consent on consent to release information forms in one of seven client records reviewed.
Client # 26 was admitted to the inpatient non-hospital activity on July 15, 2022 and was discharged on August 3, 2022. The release of information forms for the funding source and the release of information forms with purposes of the notification of admission, the notification of emergency or unplanned discharge, and the notification of seclusion or restraint were all signed and dated by the witness on July 15, 2022; however, none of the forms included the expiration date of the consent.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will provide a training on completion of Consents for Release of Information Forms to the Admissions Registration Staff.
This training will include the requirement that all forms must specify the expiration date of the consent. This training shall be completed by 09/30/2022.
The Director of Admissions will perform chart audits of a random ten charts per week to assure that the consents and release of information forms are completed correctly and contain the expiration date of the consent. These chart audits shall be performed from 9/30/22 through 10/31/2022.
The Director of Admissions will be responsible for assuring that this requirement is met and that follow up occurs with staff and, to the extent possible, the patient, if the forms do not contain the required information.
Prior to releasing any information, the Medical Records Department shall assure that the consent and/or release form was fully completed ? including the expiration date of the consent.
The Director of Admissions will be responsible for this Plan of Correction and will present the results of these audits to the Quality Management Committee meeting in November 2022.
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710.42(a)(3) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(a) The director shall be responsible for a written plan for the coordination of patient treatment and rehabilitation services which shall include, but not be limited to:
(3) Written procedures for the development, approval, and ongoing management of treatment/rehabilitation services of patients.
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Observations
Based on a review of patient records, the facility failed to follow the written procedures for the ongoing management of treatment/rehabilitation services for patients in one of one applicable patient records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Patient #14 was admitted to the inpatient hospital activity on March 11, 2022 and was discharged against medical advice on March 15, 2022; however, there was no documentation that the emergency contact was notified of the client's discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
According to Policy 4000.019, the counseling staff will call a patient's identified emergency contact after any discharge against medical advice. The nursing supervisor will have this responsibility evenings, nights and weekends. The call to the emergency contact will be documented on a case management note, a nursing progress note or AMA documentation.
The VP of Counseling (or designee) and Nursing Leader will send an alert regarding the responsibility of calling the emergency contact of any patient who leaves treatment against medical advice. Staff will sign an acknowledgement that they have read and understand the requirement, including when and where to document that the call occurred. This acknowledgment shall be obtained from all current staff prior to 9/30/2022. The acknowledgment will be obtained from all pertinent new hire counseling and nursing staff.
The VP of Counseling or designee shall perform an audit of 10% of unplanned discharges weekly to assure that, if the patient identified an emergency contact, that person was called.
The VP of Counseling shall be responsible for this corrective action plan and to follow up any noncompliance with staff. The VP of Counseling will present to the Quality Management Committee in November 2022 with the results of the audit and this Plan of Correction.
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