INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 12, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that an employee with a Bachelor's Degree met the qualifications of counselor by having a minimum of one year of clinical experience for 1 of 16 counselor records reviewed.
Employee #16 was hired as a counselor on March 26, 2020. The employee does have a qualifying Bachelor's Degree, however, the employee did not have any documented clinical experience prior to their hiring.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Counselor job description has been updated to reflect DDAP requirements for education and/or experience to include, "A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting". Human Resources has the responsibility to post all jobs and screen and verify all applicants for the appropriate level of credentials prior to commencing the position.
The Director of Human Resources will be responsible for auditing and updating job descriptions to ensure all reflect the appropriate level of credentialing. This review process will be complete by 9/30/20.
Regarding employee #16, as of 8/25/2020 her job title was changed to Recovery Educator. Employee # 16 is no longer carrying an individual caseload.
As a Recovery Educator, she is providing psycho-education, leading recovery groups performing discharge planning and completing American Society of Addiction Medicine Criteria forms (ASAM. She is working under the supervision a licensed professional counselor with the title of Clinical Coordinator.
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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 personnel records, the facility failed to document an annual written individual training plan for the current training year in 17 of the 28 personnel records reviewed.
Employee #1 was hired on September 12, 2016 and was still employed at the time of the inspection. The last documented training plan for this employee was dated August 30, 2016.
Employee #2 was hired on July 15, 2019 and was still employed at the time of the inspection. The last documented training plan for this employee was dated June 3, 2019.
Employee #4 was hired November 8, 2007 and was still employed at the time of the inspection. A blank training plan was signed by the employee on September 19, 2019.
Employee #5 was hired on December 7, 2017and was still employed at the time of the inspection. The last documented training plan for this employee was dated November 16, 2017.
Employee #7 was hired on June 6, 2019 and was still employed at the time of the inspection. The last documented training plan for this employee was dated June 4, 2019.
Employee #8 was hired on August 15, 2019 and was still employed at the time of the inspection. A training plan was to be developed for this employee no later than September 15, 2019; however, the plan was not signed and dated by the employee until October 24, 2019.
Employee #9 was hired on April 28, 2005 and was still employed at the time of the inspection. The last documented training plan for this employee was dated July 11, 2012.
Employee #10 was hired on May 1, 2014 and was still employed at the time of the inspection. The last documented training plan for this employee was dated April 15, 2014.
Employee #12 was hired on July 21, 2012 and was still employed at the time of the inspection. The last documented training plan for this employee was dated August 9, 2012.
Employee #13 was hired on June 6, 2019 and was still employed at the time of the inspection. A training plan was documented in the personnel record; however, the plan was not dated.
Employee #17 was hired on January 30, 2014 and was still employed at the time of the inspection. The last documented training plan for this employee was dated October 8, 2014.
Employee #18 was hired June 3, 2010 and was still employed at the time of the inspection. A blank training plan was signed by the employee on September 19, 2019.
Employee #20 was hired on August 1, 2019 and was still employed at the time of the inspection. A training plan was to be developed for this employee no later than September 1, 2019; however, the plan was not signed and dated by the employee until October 24, 2019.
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Employee #21 was hired February 15, 1999 and was still employed at the time of the inspection. A blank training plan was signed by the employee on September 19, 2019.
Employee #23 was hired on June 5, 2001 and was still employed at the time of the inspection. The last documented training plan for this employee was dated July 10, 2012.
Employee #24 was hired on August 15, 2019 and was still employed at the time of the inspection. A training plan was to be developed for this employee no later than September 15, 2019; however, the plan was not signed and dated by the employee until October 25, 2019.
Employee #25 was hired on August 26, 2019 and was still employed at the time of the inspection. A training plan was to be developed for this employee no later than September 26, 2019; however, the plan was not signed and dated by the employee until October 24, 2019.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Vice President of Counseling will review and sign off on all annual evaluations to ensure each employee has the appropriate annual individual training plan completed.
Counseling Leadership and Human Resources will be responsible for oversight of this corrective action plan with a completion date by 9/30/20.
The list of employees missing a training plan was sent to pertinent employee supervisors. The supervisors were instructed that they needed to complete individual training plans for their staff who did not have one and to provide the plans to Human Resources. Human Resources will conduct an audit for compliance and verify that all staff meet this requirement by 9/30/2020.
Going forward, the annual individual training plan will be completed as part of the annual evaluation process and evaluations will not be accepted without an individual training plan.
Counseling Leadership and Human Resources will be responsible for oversight of this corrective action plan with a completion date by 9/30/20.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that three employees received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as a facility director on July 15, 2019 and was due to have the communicable disease trainings no later than July 15, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #27 was hired as a counselor on October 11, 2018 and was due to have the communicable disease trainings no later than October 11, 2019. Documentation in the personnel file indicated that the employee did not complete the HIV/AIDS training until June 15, 2020.
Employee #28 was hired as a counselor on October 11, 2018 and was due to have the communicable disease trainings no later than October 11, 2019. Documentation in the personnel file indicated that the employee did not complete the HIV/AIDS training until June 14, 2020 and did not complete the TB/STD training until June 16, 2020.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Education and Training will provide oversight and tracking monthly for all employees to ensure that the trainings are completed within the first 90 days of hire. The Director will send emails to both the staff member and their immediate supervisor to ensure recognition of the importance of completing these mandatory trainings on a timely basis. This will ensure that no employee will be late or miss the training requirement.
Implementation of this ongoing procedure will begin on 9/1/2020 and continue thereafter. The Director of Clinical Education and Training will be responsible for the implementation and ongoing oversight of this plan.
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