INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2017 through August 25, 2017 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Twenty-three personnel records were reviewed on August 22, 2017 through August 25, 2017 for verification that staff met the qualifications for their position. One of 23 records reviewed, #6, lacked documention verifying that the employee met the qualifications for their position.
Employee #6 was hired as a clinical supervisor on September 15, 2016. There was no documentation contained in the record that showed that the employee functioned for two years as a supervisor in the provision of clinical services or that the employee completed a core curriculum in clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy has been revised to reflect the licensure requirement. Moving forward Eagleville will begin to follow several steps to ensure their clinical supervisory staff meet the qualifications for the position.
Any new external candidates will be required to have 2 years of clinical supervision experience or have the supervision training prior to hire.
We will to assess who may be a potential internal candidate for a supervisory position in the future. When known, those staff will be scheduled for the DDAP 5-Day Clinical Supervision Training.
Eagleville will also create its own clinical supervision training and identify alternate supervision training options and seek approval before training potential clinical supervisors. This will allow for flexibility and more timely training of multiple staff.
This plan is effective 9/27/17.
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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
Twenty-three personnel records were reviewed on August 22, 2017 through August 25, 2017. The facility failed to ensure that staff persons and volunteers received 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 within the timeframes of the regulations in 8 of 23 records reviewed.
Employee #7, a counselor, was hired on August 1, 2016. The facility failed to ensure employee #7 completed HIV/AIDS and TB/STD training by August 1, 2017.
Employee #8, a counselor, was hired on August 11, 2016. The facility failed to ensure that employee #8 completed HIV/AIDS and TB/STD training by August 11, 2017.
Employee #9, a counselor, was hired on August 17, 2016. The facility failed to ensure that employee #9 completed HIV/AIDS and TB/STD training by August 17, 2017.
Employee #19, a counselor, was hired on February 18, 2016. The facility failed to ensure that employee #19 completed TB/STD training by February 18, 2017.
Employee #20, a counselor, was hired on February 18, 2016. The facility failed to ensure that employee #20 completed TB/STD training by February 18, 2017.
Employee #21, a counselor, was hired on May 26, 2016. The facility failed to ensure that employee #21 completed HIV/AIDS and TB/STD training by May 26, 2017.
Employee #22, a counselor, was hired on November 6, 2015. The facility failed to ensure that employee #22 completed HIV/AIDS training by November 6, 2016.
Employee #23, a counselor, was hired on February 18, 2016. The facility failed to ensure that employee #23 completed HIV/AIDS training by February 18, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Eagleville is a major host site for DDAP mandatory trainings for the region. The Hospital will continue to host trainings. In order to ensure members of Eagleville Hospital staff fulfill this requirement timely, Hospital staff will now be trained to deliver the HIV and TB/STD curriculum by attending the next scheduled DDAP train-the-trainer course. This will enable the Hospital to conduct in-house sessions beginning November 15, 2017 and quarterly thereafter. The Director of Nursing and the Staff Development Manager will assume responsibility for this course of action. |
705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
A physical plant inspection was conducted on August 23, 2017. The facility failed to comply with applicable Federal, State and local laws and ordinances.
A Non-Compliance Inspection Notice " Red Tag " was observed on the fire suppression system piping in the kitchen area. When asked about the tag, facility staff provided a copy of the inspection report (dated June 2, 2017) and a proposal for bringing the system into compliance (dated June 12, 2017), noting the areas of non-compliance. The proposal had the following statement: " Failure to make timely corrections may result in the failure of the system to operate during an emergency and may place you, your employees and your business at risk from fire. "
The repairs were not completed as of the date of the inspection.
The facility has since entered into an agreement to have the work completed and provided a confirmation letter, dated August 30, 2017, from the company that will perform the repairs. The scheduled repairs are to be completed on September 8, 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Ansul fire suppressant system was corrected on September 8, 2017. Evidence of its completion and compliance is on file.
Eagleville Hospital has engaged with its third party provider to ensure that any deficiencies identified during routine inspections are personally reviewed and discussed with the Director of Facilities at the time the deficiencies are identified. At such time a remediation plan will be formulated and documented corrective measures put into place that ensure the safety of all staff and patients is made in a timely manner. Communication of these deficiencies will be shared with all key stakeholders. If for any reason the third party contractor indicates a delay in ordering parts or material, interim life safety measures will be implemented between both parties to ensure system compliance is appropriately maintained. This plan has been reviewed and agreed to with the third party provider on September 26, 2017.
When we identify any physical plant issues that require remediation, they will be addressed and corrected in a timely manner.
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of the patient records, the facility failed to ensure that records completed by the certified registered nurse practitioner were properly countersigned by the medical director or a narcotic treatment physician in one of thirteen patient records reviewed.
Patient #11 was admitted to treatment on October 19, 2016 and discharged on November 21, 2016. The history and physical examination was completed and signed by the certified registered nurse practitioner on October 19, 2016 and did was not countersigned by the medical director or a narcotic treatment physician as required.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Currently, all History and Physicals generated by a PA must be countersigned by the medical director or narcotic treatment physician. This citation will be corrected adding a field into the EMR that will force a countersignature and review by the narcotic treatment physician or medical director on all History and Physicals generated by either a CRNP or PA. The IT Clinical Analyst will implement this by October 6th. Medical Records will monitor on a random basis. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The facility failed to document a consult between the physician conducting the patient examination and the physician determining the initial dose in three of thirteen patient records reviewed during the inspection on August 22, 2017 through August 25, 2017.
Patient #1 was admitted to treatment on August 20, 2017 and was still an active client at the time of the inspection. A patient examination was completed on August 20, 2017, and the initial dose of methadone was given on August 20, 2017 by a physician other then the one who conducted the examination. There was no documentation to verify that the physician administering the initial dose consulted with the physican who conducted the exam.
Patient #5 was admitted to treatment on June 19, 2017 and was discharged on June 24, 2017. A patient examination was completed on June 20, 2017, and the initial dose of methadone was given on June 20, 2017 by a physician other then the one who conducted the examination. There was no documentation to verify that the physician administering the initial dose consulted with the physican who conducted the exam.
Patient #6 was admitted to treatment on September 23, 2016 and was discharged on September 28, 2016. A patient examination was completed on September 23, 2016, and the initial dose of methadone was given on September 24, 2016 by a physician other then the one who conducted the examination. There was no documentation to verify that the physician administering the initial dose consulted with the physican who conducted the exam.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
When the narcotic treatment physician does not complete an examination of a patient receiving methadone, that physician will be forced to select which examining physician/CRNP/PA was consulted during the methadone ordering process. This is being accomplished by editing the "Methadone Order set" to include a mandatory sub-order set with the following options:
Methadone: assessed patient personally
Methadone: consulted with assessing physician/CRNP/PA.
If the latter is chosen, the ordering practitioner must document which provider they consulted in a mandatory field. An IT Application Analyst will implement this by October 6th. Medical Records will monitor on a random basis. This policy will be will be reinforced by the Chair of the Medical Staff during the next scheduled meeting on October 4, 2017.
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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:
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Observations
Twenty-eight client records were reviewed on August 22, 2017 through August 25, 2017. The facility failed to obtain a consent to release information form for information released to a funding source in one of twenty-eight client records reviewed, specifically client record #3.
Client #3 was admitted into treatment on August 19, 2017 and was still an active client at the time of the inspection. The client record contained documentation that identified the client's funding source, but did not contain a consent to release information form for this funding source. An interview with facility staff confirmed that there was no consent to release form for the funding source, whom the facility was billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
One of 28 records lacked the consent to release information to the funding source. This release is the responsibility of the Intake and Admissions Department. The omission will be addressed by the department Director and written evidence of this discussion will be recorded in a coaching document by September 20, 2017. The patient has since been discharged on 8/24/2017. Completion of consents to release information to funding sources is a performance measure that will be monitored through monthly chart reviews. The Director of Admissions is responsible for monitoring this measure. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
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:
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Observations
Twenty-eight client records were reviewed on August 22, 2017 through August 25, 2017. The facility failed to obtain a consent to release information form for information released to a treatment provider in one of twenty-eight client records reviewed, specifically client record #11.
Client #11 was admitted into treatment on October 19, 2016 and was discharged on November 21, 2016. The client record contained documentation indicating that the facility released patient identifying information to a treatment provider on November 18, 2016 and failed to obtain an informed and voluntary consent prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
One of 28 records lacked the consent to release information to a treatment provider. This release is the responsibility of Case Management. This omission will be addressed by The Program Manager who supervises this individual. Evidence of this discussion will be recorded in a coaching document by September 20, 2017. Release of Information forms are audited monthly through chart reviews and variances are presented to the Quality Management Committee quarterly. |