INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on August 10, 2023 through August 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position in two of two applicable personnel records reviewed.
Employee #4 was hired as a clinical supervisor on September 21, 2022. There was no documentation of monthly clinical supervision meetings at the time of inspection.
Employee #37 was hired as a clinical supervisor on January 15, 2023. There was no documentation of monthly clinical supervision meetings at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR will ensure all clinical staff are following the policy of adhering to monthly supervision for
The Directors, Clinical Supervisors, Program Managers, and Clinical Coordinators (Supervisory Staff) are responsible for the monthly clinical supervision of all clinicians and students.
A copy of Employee Supervisions will be provided to HR by the 5th of each month to ensure on-going compliance.
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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 files, the facility failed to ensure that each counselor met the educational and/or the experiential qualifications for the position in two of twenty applicable personnel records reviewed.
Employee #33 was hired as a counselor on March 20, 2023. The employee does possess the required bachelor's degree with a major in a related field; however, the employee did not have the required one year of clinical experience prior to being hired.
Employee #42 was hired as a counselor on September 6, 2022. The employee does possess the required bachelor's degree with a major in a related field; however, the employee did not have the required one year of clinical experience prior to being hired.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR will ensure all clinical staff are following the policy of adhering to monthly supervision for
The Directors, Clinical Supervisors, Program Managers, and Clinical Coordinators (Supervisory Staff) are responsible for the monthly clinical supervision of all clinicians and students. For the two identified staff, EH has required that the resumes for each be updated to clearly state the relevant experience to support the requirements.
A copy of Employee Supervisions will be provided to HR by the 5th of each month to ensure on-going compliance.
HR will require a statement from all new hires attesting to the fact that they have the required training.
HR will also require a traditional resume and not one from Indeed that parses information |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure that each written individual training plan was based upon an employee's previous education, experience, current job functions, and performance in forty-two of forty-two personnel records reviewed.
In each personnel record reviewed, the individual training plans were identical. The plans were not individualized based upon each specific employee's previous education, experience, current job functions and job performance.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
HR will ensure all clinical staff are following the policy of adhering to monthly supervision for The Directors, Clinical Supervisors, Program Managers, and Clinical Coordinators (Supervisory Staff) are responsible for the monthly clinical supervision of all clinicians and students.
A copy of Employee Supervisions will be provided to HR by the 5th of each month to ensure on-going compliance. EH changed payroll systems this year and have included the annual training plans in the performance reviews. Each review will be individualized with staff goals as well as supervisors goals
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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 a review of the facility's August 2022 through June 2023 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
The facility has separate residential buildings located on their campus and the buildings listed below did not have monthly fire drills, with an evacuation of individuals within the facility:
The Birch building did not have a fire drill with evacuation during the months of December 2022, February 2023, and April 2023.
The Cedar building did not have a fire drill with evacuation during the months of September 2022, November 2022, January 2023, and June 2023
The Darclay building did not have a fire drill with evacuation during the months of December 2022, March 2023, and May 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An exception was filed by EH and was approved by the Department. EH was notified via letter on September 21, 2023.
The Director of Hospital Safety will continue to conduct table top drills on each shift as required. Staff will be trained by Director of Safety as to what exits to use during an emergency, where the appropriate equipment is stored and how to use said equipment |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's August 2022 through June 2023 fire drill logs, the facility failed to identify, on the fire drill log, which exit route was used during every fire drill conducted during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill logs have been revised to include all exits used for evacuation and detail of exact type of incidents practiced. Staff will be directed to evacuate to specified exits based on location of the client and location of the emergency; taking care to move away from the emergency.
The safety Office will be the responsible person to ensure that the fire drill logs are maintained according to regulation and will keep the logs filed accordingly |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's August 2022 through June 2023 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There were no overnight fire drills conducted during the reviewed period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An exception was filed and EH received a notification that the exception was approved on September 21, 2023.
The Director of Safety will ensure that all staff on all shifts in all units is properly trained on the appropriate use of exits, equipment and evacuation techniques via table top training. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity including the name, address, and date of birth prior to the administration of an agent in six of ten applicable patient records reviewed.
Client # 1 was admitted to the inpatient hospital detoxification activity on August 9, 2023 and was still active at the time of the inspection. There was no documentation in the record that the verification of the patient's identity was completed prior to the administration of a narcotic agent.
Client # 5 was admitted to the inpatient hospital detoxification activity on February 2, 2023 and was discharged on February 5, 2023. There was no documentation in the record that the verification of the patient's identity was completed prior to the administration of a narcotic agent.
Client # 6 was admitted to the inpatient hospital detoxification activity on June 26, 2023 and was discharged on June 29, 2023. There was no documentation in the record that the verification of the patient's identity was completed prior to the administration of a narcotic agent.
Client # 17 was admitted to the inpatient non-hospital detoxification activity on August 8, 2023 and was still active at the time of the inspection. There was no documentation in the record that the verification of the patient's identity was completed prior to the administration of a narcotic agent.
Client # 19 was admitted to the inpatient non-hospital detoxification activity on May 25, 2023 and was discharged on May 27, 2023. There was no documentation in the record that the verification of the patient's identity was completed prior to the administration of a narcotic agent.
Client # 20 was admitted to the inpatient non-hospital detoxification activity on August 7, 2023 and was discharged on August 11, 2023. There was no documentation in the record that the verification of the patient's identity was completed prior to the administration of a narcotic agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions follows policy 8130.002 by verifying patients' identities prior to treatment and determines eligibility by screening each individual
The Hospital will an EVS (Eligibility Verification System) Report on all patients to verify their information.
The process will continue. Monitoring of the process will include an audit of 20 charts between 09/15/2023 & 10/15/2023.
The Director of Patient Accounts or Designee is responsible for this plan of correction and will present the results in the November 2023 Quality Management Committee
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in two of two applicable patient records reviewed.
Patient # 6 was transferred in and admitted to the inpatient hospital detoxification activity on June 26, 2023 and was discharged on June 29, 2023. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 7 was transferred in and admitted to the inpatient hospital detoxification activity on January 31, 2023 and was discharged on February 4, 2023. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Eagleville has a current policy to address patients who are enrolled in an OTP program within the community. Nursing or Medical staff are required to notify the outpatient program of the admission to EH and they are responsible for communicating the first dose strength after verifying the outpatient services. Also the same staff is responsible for communicating the final dose provided at EH. The staff are responsible for documenting this on a form within the EMR. EH will audit 5% of the charts of those enrolled and admitted to the program during the month in the OTP monthly to ensure that the documentation is appropriately included in the EMR. |
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 facility failed to document the specific information to be disclosed on consent to release information forms in six of seven applicable client records reviewed.
Client # 15 was admitted to the inpatient non-hospital detoxification activity on August 7, 2023 and was active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on August 7, 2023. The release form stated, " the specific information to be released is that necessary for the purpose of the disclosure " ; however, the release form did not include any specific information to be released.
Client # 16 was admitted to the inpatient non-hospital detoxification activity on August 7, 2023 and was active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on August 7, 2023. The release form stated, " the specific information to be released is that necessary for the purpose of the disclosure " ; however, the release form did not include any specific information to be released.
Client # 17 was admitted to the inpatient non-hospital detoxification activity on August 8, 2023 and was active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on August 8, 2023. The release form stated, " the specific information to be released is that necessary for the purpose of the disclosure " ; however, the release form did not include any specific information to be released.
Client # 18 was admitted to the inpatient non-hospital detoxification activity on July 25, 2023 and was discharged on July 31, 2023. The release of information form to the funding source was signed and dated by the client on July 25, 2023. The release form stated, " the specific information to be released is that necessary for the purpose of the disclosure " ; however, the release form did not include any specific information to be released.
Client # 19 was admitted to the inpatient non-hospital detoxification activity on May 25, 2023 and was discharged on May 27, 2023. The release of information form to the funding source was signed and dated by the client on May 25, 2023. The release form stated, " the specific information to be released is that necessary for the purpose of the disclosure " ; however, the release form did not include any specific information to be released.
Client # 20 was admitted to the inpatient non-hospital detoxification activity on August 7, 2023 and was discharged on August 11, 2023. The release of information form to the funding source was signed and dated by the client on July 25, 2023. The release form stated, " the specific information to be released is that necessary for the purpose of the disclosure " ; however, the release form did not include any specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Patient Accounts and Billing Systems or designee will revise the release of information to the funding source form to ensure the specific information to be released is document on the form prior to submission.
The Director of Patient Accounts and Billing or designee will complete weekly chart audits to observe compliance from 09/30/2023 through 10/31/2023
Prior to releasing any information, the Medical Records Department will assure the release of information to the funding source form identifies the specific information to be released.
The Director of Patient Accounts or Designee is responsible for this plan of correction and will present the results in the November 2023 Quality Management Committee.
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711.53(a)(7) LICENSURE Follow-up Information
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes 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:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in three of four applicable client records reviewed.
Client # 26 was admitted to the inpatient non-hospital activity on December 10, 2022 and was discharged on January 6, 2023. There was no documentation of follow-up information in the record as of the date of the inspection.
Client # 27 was admitted to the inpatient non-hospital activity on September 13, 2022 and was discharged on October 11, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
Client # 28 was admitted to the inpatient non-hospital activity on October 17, 2022 and was discharged on November 2, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Counseling or Designee will ensure follow-up information is documented in the patient record for each discharge as per Policy 4000.006.
The Director of Counseling or designee will complete weekly chart audits to observe compliance from 09/30/2023 through 10/31/2023
The Counseling or Designee is responsible for this plan of correction and will present the results in the November 2023 Quality Management Committee.
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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 facility failed to document the specific information to be disclosed on consent to release information forms in six of seven client records reviewed.
Client # 22 was admitted to the inpatient non-hospital activity on July 20, 2023 and was active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on July 13, 2023. The release form stated, "the specific information to be released is that necessary for the purpose of the disclosure"; however, the form did not include any specific information to be released.
Client # 23 was admitted to the inpatient non-hospital activity on August 3, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on July 20, 2023. The release form stated, "the specific information to be released is that necessary for the purpose of the disclosure"; however, the form did not include any specific information to be released.
Client # 24 was admitted to the inpatient non-hospital activity on June 23, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client on June 16, 2023. The release form stated, "the specific information to be released is that necessary for the purpose of the disclosure"; however, the form did not include any specific information to be released.
Client # 25 was admitted to the inpatient non-hospital activity on November 20, 2022 and was discharged on December 16, 2022. The release of information form to the funding source was signed and dated by the client on November 15, 2022. The release form stated, "the specific information to be released is that necessary for the purpose of the disclosure"; however, the form did not include any specific information to be released.
Client # 26 was admitted to the inpatient non-hospital activity on December 10, 2022 and was discharged on January 6, 2023. The release of information form to the funding source was signed and dated by the client on November 15, 2022. The release form stated, "the specific information to be released is that necessary for the purpose of the disclosure"; however, the form did not include any specific information to be released.
Client # 28 was admitted to the inpatient non-hospital activity on October 17, 2022, and was discharged on November 2, 2022. The release of information form to the funding source was signed and dated by the client on November 15, 2022. The release form stated, "the specific information to be released is that necessary for the purpose of the disclosure"; however, the form did not include any specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Patient Accounts and Billing Systems or designee will revise the release of information to the funding source form to ensure the specific information to be released is document on the form prior to submission.
The Director of Patient Accounts and Billing or designee will complete weekly chart audits to observe compliance from 09/30/2023 through 10/31/2023
Prior to releasing any information, the Medical Records Department will assure the release of information to the funding source form identifies the specific information to be released.
The Director of Patient Accounts or Designee is responsible for this plan of correction and will present the results in the November 2023 Quality Management Committee.
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710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document follow-up information in two of four applicable patient records reviewed.
Patient # 5 was admitted to the inpatient hospital detoxification activity on February 2, 2023 and was discharged on February 5, 2023. The record did not include documentation of follow-up information as of the date of the inspection.
Patient # 6 was admitted to the inpatient hospital detoxification activity on June 26, 2023 and was discharged on June 29, 2023. The record did not include documentation of follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Counseling or Designee will ensure documentation of follow-up information is documented in the patient record for each discharge as per Policy 4000.006.
The Director of Counseling or designee will complete weekly chart audits to observe compliance from 09/30/2023 through 10/31/2023
The Counseling or Designee is responsible for this plan of correction and will present the results in the November 2023 Quality Management Committee.
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710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to keep patient records confidential in accordance with applicable Federal drug and alcohol regulations in seven of seven applicable patient records reviewed.
Federal regulation 42 CFR part 2 requires a written consent to release patient information to include an explicit description of the substance use disorder information that may be disclosed.
There were release of information forms to the funding source in each inpatient hospital detoxification patient record that did not document the specific information to be disclosed. Each release of information form to the funding source stated, "the specific information to be released is that necessary for the purpose of the disclosure," which is not an explicit description of the information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Patient Accounts and Billing Systems or designee will revise the release of information to the funding source form to ensure the specific information to be released is document on the form prior to submission.
The Director of Patient Accounts and Billing or designee will complete weekly chart audits to observe compliance from 09/30/2023 through 10/31/2023
Prior to releasing any information, the Medical Records Department will assure the release of information to the funding source form identifies the specific information to be released.
The Director of Patient Accounts or Designee is responsible for this plan of correction and will present the results in the November 2023 Quality Management Committee
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