INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on July 30, 2019 through August 1, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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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
The facility failed to ensure bathrooms were ventilated by an exhaust fan or operable window. Based on the physical plant inspection conducted at approximately 11:00am, both the staff restroom and the patient restroom on the third floor of Louchheim Building did not have an operable fan and the window was not able to be opened. Additionally, Bathroom C in the Arnstein Building did not have an operable fan and the window was not able to be opened.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will facilitate the appropriate ventilation of the noted areas through existing windows. The windows will be made operable to promote 4" ventilation from the window sash to the base of the window. This action is to also support the safety and well-being of patients and staff (falls risk/contraband access). Facilities has responsibility for the corrective action with a completion date scheduled for 9/15/2019. |
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
The facility failed to ensure that all heaters were permanently mounted or installed. Based on a physical plant inspection conducted at approximately 11:00am, a space heater was found in counseling office 204 in the Louchheim Building.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
During the survey all freestanding heaters were removed. To ensure compliance going forward, monthly environmental rounds will include monitoring of patient and staff areas for existence of any freestanding heaters in any building where there are patient rooms. The Safety Officer will maintain evidence of environmental rounds and notations of heaters found and removed with a completion date scheduled for 10/1/19. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to provide documentation that the narcotic treatment physician conducted the initial face-to-face with the client prior to the administration of a narcotic drug. Additionally, the required documentation of the client's 1-year history of physiological dependence and current dependency was not completed by the physician in one of three applicable client records reviewed.
Client #3 was admitted into the Inpatient Non-Hospital Detoxification activity on July 27, 2019 and was still active at the time of the inspection. The facility began administering buprenorphine to the client on June 27, 2019. The initial face-to-face meeting was conducted by the Certified Registered Nurse Practitioner and the documentation of the client's current dependence and 1-year history was completed by the CRNP on June 27, 2018.
At the time of the inspection, the facility did not have a federal exemption to allow Certified Registered Nurse Practitioners to make the face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Quality Officer will submit amended CSAT requests under DDAP Policy Bulletin Number 18-01 to allow CRNPs delegated by the NTP's medical director to perform the face-to-face determination by 9/30/19. Until the waiver is granted the Patient Safety Officer will monitor for current compliance with 715.9 by monthly random audits of MAT administration. Audit sample size will be five monthly. Audits will be submitted to the Chief Quality Officer within the first ten days of the following month. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in eight of ten client records reviewed.
Patient #11 was admitted into the Hospital Detoxification activity on July 29, 2019 and was active at the time of inspection. Consent to release information forms to the funding source, signed and dated by client, allowed for the release of all drug and alcohol history which exceeded 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Admissions will conduct monthly audits of release forms completed in admissions to monitor appropriate completion of releases. The monthly audits will include ten randomly selected charts. Audits will be submitted to the Chief Quality Officer within the first ten days of the following month. This monitoring will continue until 10/30/19. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient in the Inpatient Non-Hospital Detoxification activity. Patient record #3 was missing documentation of the patient consent to treat with a narcotic.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will conduct monthly audits of informed consents completed in admissions to monitor appropriate completion of consents. The monthly audits will include ten randomly selected charts. Audits will be submitted to the Chief Quality Officer within the first ten days of the following month. This monitoring will continue until 10/30/19. |