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 2, an abbreviated on-site inspection, conducted on March 1, 2021 through March 3, 2021 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on the physical plan inspection completed on March 3, 2021, the facility failed to maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
The two exterior hallways in the Loucheim building was observed to have peeling paint.
The third-floor group room in the Loucheim building was observed to have peeling paint.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Peeling Paint in Third-Floor Group Room
An internal work order (#6334604) to correct this deficiency was submitted on 03/03/21. The wall in the third-floor group room in the Louchheim building was painted and patched. This work order was completed by the facility's staff on 03/08/21.
Plan of Correction: Peeling Paint in Two Exterior Hallways
An internal work order (#6341285) to correct this deficiency was submitted on 03/16/21. The peeling paint in two exterior hallways in the Louchheim building were scraped. This work order was completed by the facility's staff on 03/17/21.
The Director of Operational Support oversaw the implementation and completion of this Corrective Action Plan.
She will monitor the integrity of the paint and walls on a monthly basis for the next 5 months to assure that the repair holds and that no other peeling paint conditions occur.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plan inspection completed on March 3, 2021, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
Two dumpsters outside of the Levine Dining Hall were observed to be open.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Shortly after the issue was raised during the survey, the dumpster openings were properly covered.
Beginning on 3/19/21 all Food Service staff received training on the importance of securing the dumpsters and all bins used to transport trash, garbage and rubbish. The "Exterior Trash Removal" trainings were completed by 3/23/21.
The Director of Food and Environmental Services is responsible to oversee the storage and removal of trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. He will keep logs to show that all trash, garbage and rubbish are removed at least once per week.
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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 plan inspection completed on March 3, 2021, the facility failed to ensure that there were slip-resistant surfaces in all bathtubs and showers.
The bathrooms in room numbers 229, 231, 347 and 349 of the Loucheim Building did not have slip-resistant surfaces in the showers.
The bathrooms in room numbers 1A, 202 and 205 of the Gerstley Building did not have slip-resistant surfaces in the showers.
The bathrooms in room numbers 102, 127, 203, 231 and 233 of the Levy Building did not have slip-resistant surfaces in the showers.
The bathroom in room number 143 of the D'Arclay Building did not have slip-resistant surfaces in the showers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Slip-Resistant Surfaces in bathtubs and showers:
Louchheim Building: An internal work order (#6343153) to correct this deficiency was submitted on 03/19/21. Slip-resistant strips were ordered on 03/18/21 to be installed on shower floors in the Louchheim building. This work order was completed by the facility's staff on 03/26/21.
Gerstley Building: An internal work order (#6334605) to correct this deficiency was submitted on 03/03/21. Slip-resistant strips were installed in the Gerstley building. This work order was completed by the facility's staff on 03/04/21.
Levy Building: An internal work order (#6343297) to correct this deficiency, was submitted on 03/19/21. Slip-resistant strips were ordered on 03/18/21 to be installed on shower floors in the Levy building. This work order was completed by the facility's staff on 03/26/21.
D'Arclay Building: An internal work order (#6343154) to correct this deficiency was submitted on 03/19/21. Slip resistant strips were ordered on 03/18/21 and installed on shower floors in the D'Arclay building. This work order was completed by 03/26/21.
The Director of Operational Support will be responsible for the implementation and completion of this Corrective Action Plan. To make sure that this issue is corrected, she will add it to the checklist for
Environment of Care rounds, which are performed once a month.
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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 plan inspection completed on March 3, 2021, the facility failed to ventilate toilet and washrooms by exhaust fan or window.
There was no exhaust fan or window in the first-floor staff bathroom in the D'Arclay Building.
There was no exhaust fan or window in the bathroom of room number 1 in the Arcadia Building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
D'Arclay Building: An internal work order (#6338350) to correct this deficiency was submitted on 03/10/21. Ventilation fan covers were removed, cleaned and reinstalled in the D'Arclay staff bathrooms. Both exhaust fans are now operating properly. This work order was completed on 03/16/21.
Arcadia Building: An internal work order (#6334358) to correct this deficiency was submitted on 03/03/21. The exhaust fan in room number one in the Arcadia building was replaced with a new one. This work order was completed on 03/03/21.
The Director of Operational Support was responsible for the implementation and completion of this Corrective Action Plan. To make sure this issue is corrected, checking of exhaust fans in bathrooms has been included on the checklist for Environment of Care Rounds performed once a month.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plan inspection completed on March 3, 2021, the facility failed to keep cold food at or below 40 degrees Fahrenheit.
The thermometer in the patient refrigerator of the Levy Building day room measured at 50 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The refrigerator in the Levy Building Day Room was checked and determined to be working properly. On 03/27/21, a Refrigerator/Freezer Temperature Log was posted on the refrigerator and designated nursing staff were instructed to log the refrigerator temperatures daily.
The Nurse Manager is responsible for the implementation of this Corrective Action Plan and will continue to monitor compliance on a weekly basis.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure is made in two of seven applicable client records reviewed.
Client #1 was admitted on March 24, 2020 and discharged on March 30, 2020. A release of information form to the funding source, signed and dated by the client on March 24, 2020, did not indicate the name of the person, agency or organization to whom disclosures are to be made to.
Client #17 was admitted on February 23, 2021 and was a current client at the time of the inspection. A release of information form to the funding source, signed and dated by the client on February 23, 2021, did not indicate the name of the person, agency or organization to whom disclosures are to be made to.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Consent Form for Release of Information to Insurance/Funding Sources was updated and approved by the Medical Records Committee on March 23, 2021. The revised form lists each funding source and provides checkboxes that staff will use to identify the pertinent funding source.
The Director of Admissions will educate all Admissions Department staff to ensure they are utilizing the form correctly and identifying the correct funding source. The Director of Admissions will also train the Nurse Managers who oversee the Acute Psychiatric Units because nursing staff on those units are responsible to register newly admitted patients, including assisting with completion of all consent forms. The Director of Admissions will provide this training to the relevant staff members prior to April 12, 2021 and will keep sign-in sheets to show that staff have taken the training.
Admissions Supervisors will conduct an audit of the consents of 20% of newly admitted patients each week until they reach at least 90% compliance to make sure that the forms are completed appropriately. The findings of this audit and any issues found will be reported to the Director of Admissions and the Quality Management Committee. The Director of Admissions will follow up with any issues, including coaching any staff who did not complete the form correctly.The Director of Admissions will notify the staff of the unit where the patient is being treated and assure that a new form is completed correctly.
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711.62(c)(2)(ii) LICENSURE Specific Information Disclosed
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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven applicable client records reviewed.
Client #17 was admitted on February 23, 2021 and was a current client at the time of the inspection. A release of information form to the department of corrections, signed and dated by the client on February 23, 2021, allowed for the release of histories, treatment plans, evaluations, consultation, aftercare plan, referral data and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Consent for Release of Information for Criminal Justice, Judges, Probation/Parole Officers, Corrections and Government Officials was updated and approved by the Medical Records Committee on March 23, 2021. The revised form limits the information to be released to the following: "Whether the patient is or is not in treatment, the patient's prognosis, the nature of the project, a brief description of the patient's progress, a short statement as to whether the patient has relapsed and the frequency of such relapse."
The Director of Admissions will educate all Admissions Department staff as well as the nursing staff of the Acute Psychiatric Units so they will know to use the correct form, which now is the only release form that should be used for these entities. This training will occur prior to April 12, 2021. The Director of Admissions will maintain sign-in sheets to show that staff have completed the training.
Admissions Supervisors will conduct an audit of the consents of 20% of newly admitted patients each week until they reach at least 90% compliance to make sure that the correct forms are used and completed appropriately. The findings of this audit and any issues found will be reported to the Director of Admissions and thereafter to the Quality Management Committee. The Director of Admissions will follow up on any issues and conduct coaching's with staff who used the wrong form. If the wrong form is used, the Director of Admissions will notify staff on the patient's unit and assure that they obtain the patient's consent on the correct form. The incorrect form will be destroyed to ensure information is not released in error.
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711.62(c)(2)(v) LICENSURE Dated Signature - Witness
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:
(v) The dated signature of a witness.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated witness signature in one of seven applicable client records reviewed.
Client #20 was admitted on November 6, 2020 and was discharged on November 11, 2020. A witness signature was not documented on a release of information form for a family member, signed and dated by the client on November 9, 2020.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director of Admissions will educate all admissions staff on the requirement that consent forms must be witnessed and contain a witness signature. The Director of Admissions will also train the Nurse Managers who oversee the Acute Psychiatric Units, as nursing staff complete consents on these units. The training of all pertinent staff will occur prior to April 12, 2021. The Director of Admissions will maintain sign-in sheets to show that staff have been trained on the importance of proper completion and witnessing of forms.
Admissions Supervisors will audit 20% of new admissions per week until they reach at least 90% compliance with the requirement of witness signatures. They will report their findings and any issues to Director of Admissions and the Quality Management Committee. The Director of Admissions will follow-up to identify and coach any staff who did not complete the forms correctly. If the consent form lacks a witness signature, the patient's unit will be notified and will have a new form signed by the patient, witnessed, and signed by the witness.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure is made in two of seven applicable client records reviewed.
Client #4 was admitted on February 26, 2021 and was current at the time of the inspection. A release of information form to the funding source, signed and dated by the client on February 26, 2021, did not indicate the name of the person, agency or organization to whom disclosures are to be made to.
Client #13 was admitted on June 5, 2020 and was discharged on June 15, 2020. A release of information form to the funding source, signed and dated by the client on June 5, 2020, did not indicate the name of the person, agency or organization to whom disclosures are to be made to.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Consent Form for Release of Information to Insurance/Funding Sources was updated and approved by the Medical Records Committee on March 23, 2021. The revised form lists each funding source and provides checkboxes that staff will use to identify the pertinent funding source.
The Director of Admissions will educate all Admissions Department staff to ensure they are utilizing the form correctly and identifying the correct funding source. The Director of Admissions will also train the Nurse Managers who oversee the Acute Psychiatric Units because nursing staff on those units are responsible to register newly admitted patients, including assisting with completion of all consent forms. The Director of Admissions will provide this training to the relevant staff members prior to April 12, 2021 and will keep sign-in sheets to show that staff have taken the training.
Admissions Supervisors will conduct an audit of the consents of 20% of newly admitted patients each week until they reach at least 90% compliance to make sure that the forms are completed appropriately. The findings of this audit and any issues found will be reported to the Director of Admissions and the Quality Management Committee. The Director of Admissions will follow up with any issues, including coaching any staff who did not complete the form correctly. The Director of Admissions will notify the staff of the unit where the patient is being treated and assure that a new form is completed correctly.
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711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven applicable client records reviewed.
Client #16 was admitted on September 23, 2020 and was a current client at the time of the inspection. A release of information form to a county probation agency, signed and dated by the client on December 18, 2020, allowed for the release of histories, evaluations, aftercare plan, referral data and discharge summary, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Consent for Release of Information for Criminal Justice, Judges, Probation/Parole Officers, Corrections and Government Officials was updated and approved by the Medical Records Committee on March 23, 2021 to limit the information to be released to these entities. The form specifically states that the only information to be released is the following: whether the patient is or is not in treatment, the patient's prognosis, the nature of the project, a brief description of the patient's progress, a short statement as to whether the patient has relapsed and the frequency of such relapse.
The Director of Admissions will educate all Admissions Department staff to ensure they are utilizing the form correctly and that this is the only release form used for these entities. The Director of Admissions will also train the nurse managers who oversee the acute psychiatric units, as nursing staff completes consents on this unit. Training will occur prior to April 12, 2021. Staff will sign off that they have been trained on the appropriate use of this form.
Admissions Supervisors will audit 20% of new admits per week until they reach at least 90% compliance and will report their findings and any issues to Director of Admissions and the Quality Management Committee. The Director of Admissions will follow up on any issues and conduct coachings with staff who used the wrong form. If the wrong form is used, the Director of Admissions will notify staff on the patient's unit and assure that they obtain the patient's consent on the correct form. The incorrect form will be destroyed to ensure information is not released in error.
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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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated witness signature in one of seven applicable client records reviewed.
Client #16 was admitted on September 23, 2020 and was a current client at the time of the inspection. A witness signature was not documented on a release of information form for a county probations agency, signed and dated by the client on December 18, 2020.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director of Admissions will educate all Admissions Department staff to ensure they are witnessing all documents that require a witness signature. The Director of Admissions will also train the nurse managers who oversee the acute psychiatric units, as nursing staff completes consents on this unit. Training will occur prior to April 12, 2021. The Director of Admissions will maintain sign-in sheets to show that all pertinent staff have been trained on the importance of proper completion and witnessing of forms.
Admissions Supervisors will audit 20% of new admissions per week until they reach at least 90% compliance with the requirement of witness signatures. They will report their findings and any issues to Director of Admissions and the Quality Management Committee. The Director of Admissions will follow-up to identify and coach any staff who did not complete the forms correctly. If the consent form lacks a witness signature, the patient's unit will be notified and will have a new form signed by the patient, witnessed, and signed by the witness.
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