INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on December 17-18, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Eagleville Hospital. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
|
Plan of Correction
|
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to protect a client ' s civil rights by violating a client ' s right to privacy.
Client #1 was admitted to the facility on 3/13/2018. The facility failed to ensure this client ' s right to privacy during a search of his person and his room which was conducted in view of other residents in the community. Client #1 filed a grievance and it was determined that the facility did not meet expectations regarding his privacy.
|
Plan of Correction
The general consent form, as of 3/13/2018, included language regarding searches of persons, belongings and rooms. The general consent form will be revised to include a more specific description of the patient/belongings search process. The Patient Handbook was revised March 2019 to better inform patients that it might be necessary for staff to conduct searches of patients, clothing, living areas, bedrooms and personal belongings to maintain a safe drug and alcohol free environment that is supportive of recovery. Patient Searches and Securing Patient Belongings policy, will clarify the privacy requirements during different types of searches. The revision will include trauma informed procedures. The VP of Counseling will be responsible for making these changes by 3/10/2020. Education on the policy changes will be completed by 3/13/2020. |
711.62(c)(2) LICENSURE Informed & Voluntary Consent
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:
|
Observations
The facility failed to ensure the confidentiality of client records.
Based on a review of personnel records and disciplinary actions it was confirmed that a facility staff member released information from a client ' s record to an individual without obtaining consent.
|
Plan of Correction
The unauthorized release of information was immediately investigated by the Chief Legal Officer. The action was in clear violation of Eagleville's confidentiality policy and training. As stated, disciplinary action was taken as resolution to the completed investigation. The patient was informed of the findings of the investigation.
Eagleville Hospital will require all employees to complete an annual training that includes confidentiality laws and expectations. As a corrective action the Director of IT, Director of Medical Records and the Chief Legal Officer will evaluate access privileges for all employees to determine potential areas of improvement in limiting access and to establish quarterly monitoring protocols. This evaluation and monitoring protocol will be established and implemented by February 15, 2020.
|
711.53(a)(6) LICENSURE Aftercare Plan
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plan, if applicable.
|
Observations
The facility failed to document an aftercare plan in one of three applicable records.
Client #2 was successfully discharged from the facility on 6/5/19.
There was no aftercare plan documented at the time of the investigation.
|
Plan of Correction
Our policy currently indicates that aftercare planning begins at the time of admission. The policy will be updated to include additional timeframes for required documentation of the ongoing aftercare planning process.
Clinical notes will be audited by counseling staff for timeliness of documentation regarding aftercare planning for 2 months. The VP of Counseling will be responsible to update the policy, assure training and monitoring of this corrective action to be completed by March 31, 2020.
|