INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9th through 13th, 2012 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on the physical plant inspection, the facility failed to maintain lounge areas with furnishings which were in good repair.
The findings include:
The physical plant inspection was conducted on July 11, 2012. At approximately 9:30 a.m., the lounges were inspected. There were four armchairs that were worn and missing fabric on the cushions in the lounge room identified as #117; they also appeared to be dirty.
The findings were confirmed with the Director of Quality Management.
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Plan of Correction
# P015 The furnishings were immediately removed from lounge area and replaced with hard surface chairs. Additional chairs have been ordered
The Director of Plant operations will review the furnishing on monthly basis during the facility inspection. He will report finding to the Chief Clinical Officer and Director of Quality Management Quarterly at the Safety Meeting
By:Director of Plant Operations |
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 on the physical plant inspection, the facility failed to provide privacy in toilets with required doors.
The findings include:
The physical plant inspection was conducted on July 11, 2012. At approximately 9:30 a.m., bedrooms and bathrooms were inspected. The facility used curtains for the entrance to the toilet area on the psychiatric unit.
The Facility Director and campus engineer confirmed the findings.
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Plan of Correction
#P061
The Director of Plant Operations and Chief Clinical Officer will be exploring alternative choice for doors that could be installed with an Environmental Behavioral Facilities Specialist to address how you will come into compliane, BY August 31, 2012
A waiver letter will be submitted to seek approval to be in compliance with this requirement.
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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 on the physical plant inspection, the facility failed to provide ventilation by fans or windows for bathrooms.
The findings include:
The physical plant inspection was conducted on July 11, 2012. At approximately 9:30 a.m., bathrooms were inspected. The facility had several exhaust fans in the bathrooms identified as rooms 214, 229, 231 and 233 of Louchheim building that were not functioning and no windows were in place.
The findings were confirmed with the Director of Quality Management.
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Plan of Correction
# P063
The Director of Plant Operations was informed of the problem. A problem was identified with central ventilation in this area. A repair of the ventilation fans in affected rooms will be corrected. By September 28, 2012
Ventilation fans in bathrooms without windows will be added to facility inspection monthly. The Director of Plant Operations will report finding to the Chief Clinical Officer and Director of Quality Management Quarterly at the Safety Meeting
By September 28, 2012
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on administrative documentation, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
The August 2011 to June 2012 fire drill logs were reviewed on July 10, 2012. The facility failed to document a fire drill for D'Arclay building in September 2011 and for Price building in October 2011.
The findings were confirmed with the Director of Quality Management.
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Plan of Correction
# P141
The Quality Management Committee monitored fire drill completion for fiscal year 2012. Several actions were taken during fiscal year 2012 to ensure fire drills are being conducted on a monthly basis. Actions taken include: 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 October 2012 fire drills are being conducted in every building on a monthly basis. The D'Arclay building was completed September 2011 and fire alarm was pulled however, the alarm failed to sound. Director of Plant Operations was notified and a repair service was called to complete repairs immediately. The Staff was notified that the fire pull failed to alarm and to utilize back up plan. Staff was informed to be alert and complete rounding every hour or more and watching for any sign of a fire.
They were instructed at the first sign of smoke or flames, to call a "CODE RED" on the 2-way
radio and then call 911 for the fire department.
The Price building at the time noted in was not included at the time of the implementation of every building every month since it is a non -sleeping quarters.
1. All staff responsible for conducting fire drills will be reeducated and counseled on the requirements of conducting the fire drill for the designated building and shift during the month that it is scheduled as well as the completion of the forms
2. The Engineering Supervisor will monitor fire drill completion on a weekly basis for a period of two months to ensure all fire drills are being conducted as scheduled. The Engineering Supervisor will take corrective actions as necessary.
3. The Quality Management Committee will continue to monitor fire drill completion on a monthly basis.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on July 10, 2012. The fire drill logs were reviewed for documentation of fire drills from the time period of August 2011 to June 2012 for all buildings. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for 7 fire drills.
The findings were confirmed with the Director of Quality Management.
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Plan of Correction
#P155
All staff responsible for conducting fire drills will be re-educated on activating the fire alarm or smoke detector and counseled on the requirements of conducting the fire drill for the designated building and shift during the month that it is scheduled, as well as the completion of the forms.
The Plant Operation assistant will monitor fire drill logs for completion and ensure that that a smoke detector or fire alarm had been activated
By September 28, 2012
1. The Quality Management Committee will continue to monitor fire drill completion on a monthly basis.
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157.21 (b)(4) LICENSURE Admission - detoxification
157.21 Admission - detoxification.
(b) Admission procedures shall include documentation of the following:
(4) Psychosocial evaluation.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial assessment and/or failed to document a psychosocial assessment in accordance with the facility's policies and procedures in six hospital detoxification patient records.
The findings include:
In reference to biopsychosocial evaluations the facility's policy states that they should be completed within four days of admission into hospital detox.
On July 13, 2012, eight hospital detoxification patient records were reviewed for psychosocial evaluations. Six out of eight patient records lacked documentation of a clinical assessment within four days, specifically client records # 3, 4, 5, 6, 7, and 8.
Patient # 3 was admitted on July 6, 2012. The psychosocial evaluation was due by July 10, 2012 but had not been completed until July 11, 2012
Patient # 4 was admitted on July 4, 2012. The psychosocial evaluation was due by July 8, 2012 but had not been completed until July 9, 2012.
Patient # 5 was admitted on July 4, 2012. The psychosocial evaluation was due by July 8, 2012 but had not been completed until July 9, 2012.
Patient # 6 was admitted on July 6, 2012. The psychosocial evaluation was due by July 10, 2012, as of the date of inspection, there was no documentation of a psychosocial evaluation for patient #6.
Patient # 7 was admitted on April 7, 2012 and discharged on April 12, 2012. The psychosocial evaluation was due by April 11, 2012 but had not been completed until April 13, 2012.
Patient # 8 was admitted on April 13, 2012 and discharged on April 19, 2012. The psychosocial evaluation was due by April 17, 2012 but had not been completed until April 19, 2012.
During the exit interview, on July 13, 2012, it was confirmed that the biopsychosocial evaluations were late or missing.
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Plan of Correction
#H117
Eagleville Hospital intends to utilize an Excel based assessment and treatment planning scheduling system to facilitate timely scheduling, completion, and tracking of assessments and treatment plans conducted by Counseling Services staff. A key element in this system will be the psychosocial assessment. This system will be implemented in the hospital detoxification program initially and then expanded to all other D&A programs. This system was implemented in the hospital detoxification unit several months ago. The system will be adjusted to prioritize completion of biopsychosocial evaluation within the time frames defined in policy. We are confident that this system will serve as an interim step in assuring compliance with timeframes defined in policy as we move toward our implementation new electronic medical record system.
Director of Counseling and Community Services Implementation on hospital detoxification unit by 9/1/2012
Timeliness of completion of psychosocial evaluations will be added to existing Quality Management chart review processes completed monthly and reported quarterly to the Quality Management Committee.
Director of Quality Management By September 28, 2012
All Counseling Services staff will receive training in the core components of assessment and treatment planning, including review of regulations, hospital policy, best practice, and the new Excel system. This training will be added as a mandatory annual training for Counseling Services staff.
Timeliness of completion of psychosocial evaluations will be added to existing Quality Management chart review processes completed monthly and reported quarterly to the Quality Management Committee.
By Clinical Development Manager and Director of Counseling and Community Services & Director of Quality Management September 28, 2012
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157.42 (b)(2) LICENSURE Treatment and rehabilitation services.
157.42 Treatment and rehabilitation services.
(b) An individual treatment and rehabilitation plan shall be developed with each patient. This plan shall include, but not be limited to written documentation of the following:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in eight of eight inpatient hospital client records.
The findings include:
On July 12, 2012, eight inpatient hospital client records were reviewed for treatment plans. Eight out of eight inpatient hospital client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 10, 11, 13, 14, 15, 16, 17, and 18.
Client # 10 was admitted on July 3, 2012. The treatment plan was completed on July 10, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 11 was admitted on July 2, 2012. The treatment plan was completed on July 9, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 13 was admitted on May 22, 2012. The treatment plan was completed on May 23, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 14 was admitted on March 30, 2012. The treatment plan was completed on April 4, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 15 was admitted on May 7, 2012. The treatment plan was completed on May 9, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 16 was admitted on March 22, 2012 and discharged on April 12, 2012. The treatment plan was completed on March 29, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 17 was admitted on March 5, 2012 and discharged on April 3, 2012. The treatment plan was completed on March 12, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 18 was admitted on May 18, 2012 and discharged on June 11, 2012. The treatment plan was completed on May 21, 2012 and did not include the type and frequency of treatment and rehabilitation services.
On July 12, 2012 an interview was conducted with the clinical director, which confirmed the treatment plans lacked documentation of the type and frequency.
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Plan of Correction
#H165
Training in assessment and treatment planning will include the importance of type and frequency of service being documented in treatment plans. This training will consist of review of regulation, policy and procedure, and utilizing the free text function of our electronic medical record to document type and frequency of service.
By Clinical Development Manager and Director of Counseling and
Community Services By September 28, 2012
Documentation of type and frequency of service will be added to the existing Quality Management chart review processes.
Quality Management Chart Review processes completed monthly and reported quarterly to the Quality Management Committee.
As the hospital moves toward implementation of a new EMR we will assure that type and frequency of service are required elements for the completion and filing of treatment plans. Director of Quality Management Director of Counseling and
Community September 28, 2012
EMR Team At Implementation
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157.42 (b)(3) LICENSURE Treatment and rehabilitation services.
157.42 Treatment and rehabilitation services.
(b) An individual treatment and rehabilitation plan shall be developed with each patient. This plan shall include, but not be limited to written documentation of the following:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the proposed type of support services in five of eight inpatient hospital client records.
The findings include:
On July 12, 2012, eight inpatient hospital client records were reviewed for treatment plans. Five out of eight inpatient hospital client records lacked documentation of a treatment plan that included the proposed type of support services, specifically client records # 10, 11, 13, 14, and 15.
Client # 10 was admitted on July 3, 2012. The treatment plan was completed on July 10, 2012 and did not include the proposed type of support services .
Client # 11 was admitted on July 2, 2012. The treatment plan was completed on July 9, 2012 and did not include the proposed type of support services.
Client # 13 was admitted on May 22, 2012. The treatment plan was completed on May 23, 2012 and did not include the proposed type of support services.
Client # 14 was admitted on March 30, 2012. The treatment plan was completed on April 4, 2012 and did not include the proposed type of support services.
Client # 15 was admitted on May 7, 2012. The treatment plan was completed on May 9, 2012 and did not include the proposed type of support services.
On July 12, 2012 an interview was conducted with the clinical director, which confirmed the treatment plans lacked documentation of the proposed type of support services.
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Plan of Correction
#H167
A re-education and training in assessment treatment planning will include the importance of proposed support services being documented in treatment plans. This training will consist of review of regulation, policy and procedure, and utilizing the free text function of our electronic medical record to identify and document type and support services.
By Clinical Development Manager and Director of Counseling and
Community Services
Documentation of support services will be added to the existing Quality Management Chart Review processes completed monthly and reported quarterly to the Quality Management Committee Director of Quality Management By September 28, 2012
As the hospital moves toward implementation of a new EMR we will assure that support services are required elements for the completion and filing of treatment plans.EMR Team
At implementation
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711.14(b)(5) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on the review of the staffing requirements facility summary report, the facility failed to maintain the authorized maximum capacity of 192 and 22.
The findings include:
The staffing requirements facility summary report, completed by the facility, was reviewed on July 9, 2012. The staffing requirements facility summary listed 196 patients in non-hospital drug-free. The number of current active clients and the maximum number of clients that the facility is allotted is 192 for non-hospital drug-free. The facility is currently over maximum capacity by 4. The staffing requirements facility summary listed 23 patients in hospital detoxification. The number of current active clients and the maximum number of clients that the facility is allotted is 22 for hospital detoxification. The facility is currently over maximum capacity by 1.
The findings were confirmed with the facility director and the Director of Quality Management on July 9, 2012.
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Plan of Correction
The Director of Facility while completing the facility summary report made a transcription error in his report and listed 196 for current number of patients in non ?hospital drug free. The correct number was 176. This error was not initially recognized at the time of the survey. The Facility Director and the Director of Quality Management did not confirm the numbers of patients list on the facility summary.
The Director of Quality Management and Director of Facility will double check total census and numbers of patients prior to submission of Facility Summary report in future surveys.
The number of current active clients and the maximum number of clients that the facility is allotted is 22 for hospital detoxification. The facility was currently over maximum capacity by one due to a walk-in patient that was deemed by medical evaluation not safe to release.
The facility was over by maximum capacity by one due to accommodation of walk- in and pregnant women.
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711.52(c)(2) LICENSURE Type/Frequency of TX
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services in eight of fourteen inpatient non-hospital client records.
The findings include:
On July 12, 2012, fifteen inpatient non-hospital client records were reviewed for treatment plans. Eight out of fourteen inpatient non-hospital client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records #25, 29, 31, 32, 34, 35, 37, and 38.
Client # 25 was admitted on May 14, 2012. The treatment plan was completed on May 25, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 29 was admitted on June 15, 2012. The treatment plan was completed on June 22, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 31 was admitted on March 5, 2012 discharged on April 16, 2012. The treatment plan was completed on March 7, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 32 was admitted on May 30, 2012 discharged on June 24, 2012. The treatment plan was completed on June 7, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 34 was admitted on April 27, 2012 discharged on June 29, 2012. The treatment plan was completed on May 4, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 35 was admitted on January 24, 2012 and discharged on April 18, 2012. The treatment plan was completed on January 31, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 37 was admitted on March 19, 2012 and discharged on April 4, 2012. The treatment plan was completed on March 27, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client # 38 was admitted on April 3, 2012 and discharged on April 26, 2012. The treatment plan was completed on April 10, 2012 and did not include the type and frequency of treatment and rehabilitation services.
On July 12, 2012 an interview was conducted with the clinical director, which confirmed the treatment plans lacked documentation of the type and frequency of services.
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Plan of Correction
#0787
Training in assessment and treatment planning will include the importance of type and frequency of service being documented in treatment plans. This training will consist of review of regulation, policy and procedure, and utilizing the free text function of our electronic medical record to document type and frequency of service.
Clinical Development Manager and Director of Counseling and
Community Service By September 28, 2012
Documentation of type and frequency of service will be added to the existing Quality Management chart review processes.
Quality Management Chart Review processes completed monthly and reported quarterly to the Quality Management Committee. Director of Quality Management By September 28, 2012
As the hospital moves toward implementation of a new EMR we will assure that type and frequency of service are required elements for the completion and filing of treatment plans.
EMR Team At Implementation
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711.52(c)(3) LICENSURE Support Service
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the proposed type of support services in six of fourteen inpatient non-hospital client records.
The findings include:
On July 12, 2012, fourteen inpatient non-hospital client records were reviewed for treatment plans. Six out of fourteen inpatient non-hospital client records lacked documentation of a treatment plan that included the proposed type of support services, specifically client records # 25, 27, 29, 30, 35, and 36.
Client # 25 was admitted on May 14, 2012. The treatment plan was completed on May 25, 2012 and did not include the proposed type of support services.
Client # 27 was admitted on June 5, 2012. The treatment plan was completed on June 12, 2012 and did not include the proposed type of support services.
Client # 29 was admitted on June 15, 2012. The treatment plan was completed on June 22, 2012 and did not include the proposed type of support services.
Client # 30 was admitted on May 14, 2012. The treatment plan was completed on May 21, 2012 and did not include the proposed type of support services.
Client # 35 was admitted on January 24, 2012 and discharged on April 18, 2012. The treatment plan was completed on January 31, 2012 and did not include the proposed type of support services.
Client # 36 was admitted on April 9, 2012 and discharged on June 4, 2012. The treatment plan was completed on April 16, 2012 and did not include the proposed type of support services.
On July 12, 2012 an interview was conducted with the clinical director, which confirmed the treatment plans lacked documentation of the proposed type of support services.
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Plan of Correction
Training in assessment and treatment planning will include the importance of type and frequency of service being documented in treatment plans. This training will consist of review of regulation, policy and procedure, and utilizing the free text function of our electronic medical record to document support service offered
Clinical Development Manager and Director of Counseling and
Community Service By September 28, 2012
Documentation of support service offered service will be added to the existing Quality Management chart review processes.
Quality Management Chart Review processes completed monthly and reported quarterly to the Quality Management Committee. Director of Quality Management By September 28, 2012
As the hospital moves toward implementation of a new EMR we will assure that type and frequency of service and suppoirt services offered are required elements for the completion and filing of treatment plans.
EMR Team At implementation |